{"paper_id":"40c1d2a7-28c9-4bb0-8172-60f999578be0","body_text":"1\n1 A Mixed-Methods Comparison of Gender Differences in Alcohol Consumption and \n2 Drinking Characteristics among Patients in Moshi, Tanzania\n3\n4 Authors and affiliations:\n5 Alena Pauley MScGH1 – alena.pauley@duke.edu (ORCID#: 0000-0002-7489-7469)\n6 Mia Buono1 – mia.buono@duke.edu\n7 Kirstin West1 – kirstin.west@duke.edu\n8 Madeline Metcalf1 – madeline.metcalf@duke.edu\n9 Sharla Rent, MD MScGH1,2 - Sharla.Rent@duke.edu \n10 Joseph Kilasara3,5 APRN MNS-FNP– joseph.kilasara@kcmuco.ac.tz\n11 Yvonne Sawe3 – yvonnesawe90@gmail.com\n12 Mariana Mikindo3 – mirianamikindo@gmail.com \n13 Blandina T. Mmbaga, MD PhD3,4,5  – blaymt@gmail.com\n14 Judith Boshe MD MMED3,5 – jboshe@live.com\n15 João Ricardo Nickenig Vissoci MBA MSc PhD1,6   – jnv4@duke.edu  \n16 Catherine A. Staton, MD MScGH1,6   – catherine.staton@duke.edu \n17\n18 1 Duke Global Health Institute, Duke University, Durham, NC USA\n19 2 Duke Department of Pediatrics, Duke University Medical Center, Durham, NC USA\n20 3 Kilimanjaro Christian Medical Center, Moshi, Tanzania\n21 4 Kilimanjaro Clinical Research Institute, Moshi, Tanzania\n22 5 Kilimanjaro Christian Medical University College, Moshi, Tanzania\n23 6 Duke Department of Surgery, Duke University Medical Center, Durham, NC USA\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\n24\n25 Corresponding Author in event of publication: catherine.lynch@duke.edu (CAS)\n26 ORCID#: 0000-0002-6468-2894\n27\n28 Funding: This project was funded by the Duke Global Health Institute Graduate Student funds, \n29 and the Josiah Trent Foundation.  Infrastructure built by NIH grant R01 AA027512 (PI Staton) \n30 was used to support the data collection process for this grant to understand gender related aspects \n31 of alcohol use at KCMC.\n32 Competing interests: The authors declare no competing interests\n33\n34 Author contributions:\n35 Conceptualization: AMP, CAS, BTM, JB\n36 Methodology: AMP, CAS, JRNV\n37 Formal analysis and investigation: CAS, BTM, JB\n38 Data Collection: JK, YS, MMi, AMP\n39 Writing - original draft preparation: AMP, MB, KW, MM\n40 Writing - review and editing: SR, AMP, MB, KW, MM, CAS\n41 Funding acquisition: AMP, CAS\n42 Supervision: CAS, JRNV, BTM\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n3\n43 ABSTRACT\n44 Background: Excessive alcohol use stands as a serious threat to individual and community well-\n45 being, having been linked to a wide array of physical, social, mental, and economic harms. \n46 Alcohol consumption differs by gender, a trend seen both globally and in Moshi, Tanzania, a \n47 region with especially high rates of intake and few resources for alcohol-related care. To develop \n48 effective gender-appropriate treatment interventions, differences in drinking behaviors between \n49 men and women must be better understood. Our study aims to identify and explore gender-based \n50 discrepancies in alcohol consumption among Kilimanjaro Christian Medical Center (KCMC) \n51 patients.\n52 Methods: A systematic random sampling of adult patients presenting to KCMC’s Emergency \n53 Department (ED) or Reproductive Health Center (RHC) was conducted from October 2020 until \n54 May 2021. Patients answered demographic and alcohol use-related questions and completed \n55 brief surveys including the Alcohol Use Disorder Identification Test (AUDIT). Through \n56 purposeful sampling, 19 subjects also participated in in-depth interviews (IDIs) focused on \n57 identifying gender differences in alcohol use.\n58 Results: During the 8-month data collection timeline, 655 patients were enrolled. Men and \n59 women patients at KCMC’s ED and RHC were found to have significant differences in their \n60 alcohol use behaviors including lower rates of consumption among women, (average [SD] \n61 AUDIT scores were 6.76 [8.16] among ED men, 3.07 [4.76] among ED women, and 1.86 [3.46] \n62 among RHC women), greater social restrictions around women’s drinking, and more secretive \n63 alcohol use behaviors for where and when women would drink. For men, excess drinking was \n64 normalized within Moshi, tied to men’s social interactions with other men, and generally \n65 motivated by stress, social pressure, and despair over lack of opportunity.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n4\n66 Conclusion: Significant gender differences in drinking behaviors were found, primarily \n67 influenced by sociocultural norms. These dissimilarities in alcohol use suggest that future \n68 alcohol-related programs should incorporate gender in their conceptualization and \n69 implementation. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n5\n70 Introduction \n71 Alcohol use is a leading risk factor for death and disability-adjusted life years (DALYs) \n72 worldwide, accounting for over 3 million deaths each year (1,2). Globally, alcohol use and \n73 alcohol-related harm are increasing, especially so within low-and middle-income countries(3). \n74 For example, the World Health Organization (WHO) Africa region consumes on average 20% \n75 more alcohol per day (40.0g/day) than the global average (32.8g/day), with Tanzania ingesting \n76 especially large quantities. The rate of heavy episodic drinking in Tanzania (7.7% among women \n77 and 33.4% among men 15 years or older), is almost twice that of neighboring countries (1).  \n78 Moshi, a popular tourist town located at the base of Mount Kilimanjaro in Northern Tanzania, \n79 has particularly high rates of alcohol use, which have also been increasing in recent years \n80 compared to nearby regions (4–6). This increase is influenced by a strong drinking culture and a \n81 custom of early alcohol initiation in minors for members of the Chagga ethnic group who \n82 constitute the majority of local inhabitants (7,8). Standing also as contributing factors is \n83 alcohol’s ready availability mixed with its low cost and a recent increase in disposable income \n84 among local inhabitants (4,7,9).  \n85 Both globally and within Tanzania, alcohol consumption patterns and alcohol-related \n86 harms are dissimilar among men and women (10–15). On average, men consume alcohol in \n87 higher quantities and more frequently than women, with a higher prevalence of Alcohol Use \n88 Disorder (AUD) worldwide (11,16,17). Men are also more likely to engage in injurious \n89 behaviors like drunk driving, violence, and crime while under the influence (18,19). While \n90 women intake less alcohol, drinking can reduce inhibitions and awareness of risk, increasing the \n91 likelihood of women being subject to unsafe scenarios like violence or sexual assault which in \n92 turn increases the risk of acquiring sexually transmitted diseases (20–23). For women who are \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n6\n93 pregnant, alcohol use also can introduce harm to themselves and their unborn child (24,25). \n94 Sociocultural factors and norms are also known to impact alcohol consumption and use \n95 behaviors. Among youth in both Tanzania and nearby Kenya, young people who spent time \n96 around those already consuming alcohol or encouraging alcohol use were found to have higher \n97 rates of intake themselves (7,26).\n98 In Tanzania specifically, little is known on how or why alcohol use differs between \n99 genders. The data that does exist has indicated that while intoxicated, men are more likely to \n100 exhibit violent behaviors while women are more likely to be victims of violence. For example, \n101 men exhibit a greater prevalence of alcohol use and abuse, a greater risk of injury after drinking, \n102 are more likely to incur road-traffic injuries, and have more public displays of alcohol intake \n103 compared to women (13,15,27).  In contrast, alcohol consumption among women in the region \n104 increases the risk of experiencing sexual violence and contracting sexually transmitted infections \n105 (28). Estimates for alcohol abuse have ranged from 7% among women with partners and 22.8% \n106 among men in the general population (4),  to an AUD prevalence of 38.7% among men and \n107 13.1% among women patients at a local outpatient clinic (29).  \n108 To reduce the burden associated with alcohol in Moshi, more research about how and \n109 why alcohol intake varies between genders is needed. Given the known discrepancies in alcohol \n110 use by men and women, this information can be used to design and implement more effective \n111 alcohol-reduction programs that are both gender and culturally appropriate in this region. \n112 Addressing this knowledge gap, this study aims to better understand the key gender differences \n113 in alcohol consumption and use patterns among patients in Moshi, Tanzania.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n7\n114 Methods\n115 Overview\n116 This was a sequential explanatory mixed-methods study that combined quantitative \n117 survey score data and qualitative semi-structured in-depth interviews (IDIs). Quantitative data \n118 was collected prior to IDIs to guide qualitative data sampling, with all data collection procedures \n119 occurring from October 2021 until May of 2022 at the Kilimanjaro Christian Medical Centre \n120 (KCMC) in Moshi, Tanzania (Figure 1). In total, 655 subjects participated in survey \n121 questionnaires, and of those individuals, 19 were selected, via purposeful sampling, to participate \n122 in IDIs addressing alcohol use. \n123 Figure 1: Study Design Overview\n124\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n8\n125 Setting\n126 This study was based within the Kilimanjaro Christian Medical Center (KCMC), a large \n127 referral and teaching hospital that serves over 1.9 million people (6). KCMC is located in Moshi, \n128 an urban town of over 200,000 residents situated in Northern Tanzania and bordering Kenya and \n129 Kilimanjaro National Park. This study operated specifically within two clinical units at KCMC, \n130 the Emergency Department (ED) and the Outpatient Unit for Gynecology, commonly referred to \n131 as the Reproductive Health Centre (RHC).\n132 For the Kilimanjaro region, KCMC’s ED serves as the referral unit for all injury patients. \n133 Injuries have long been associated with excessive alcohol use (30–32). Thus, given the high \n134 concentration of injury patients at KCMC’s ED, this clinical unit is ideal for studying risky \n135 alcohol users and use behaviors. KCMC’s RHC serves as the referral unit for all women seeking \n136 gynecological care within the Kilimanjaro region. The RHC’s large women patient population \n137 was chosen to facilitate a deeper understanding of women’s drinking patterns while also \n138 providing a safe, gynocentric environment for collecting the sensitive information needed for this \n139 study. Data was collected in parallel at KCMC’s ED and RHC throughout the 8-month \n140 enrollment timeline. Conducting this research at these locations allowed us to more accurately \n141 compare alcohol use behaviors, risky drinking in particular, among both men and women \n142 patients.\n143 Participants\n144 All enrolled participants met the following eligibility criteria: 1) were 18 years of age or \n145 older, 2) had the capacity to give informed consent, 3) received initial care at KCMC’s \n146 Reproductive Health Center or Emergency Department, 4) were conversant in KiSwahili, and 5) \n147 were not prisoners. Capacity to provide informed consent was defined as being medically \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n9\n148 stabilized, clinically sober, and well enough to complete the survey verbally on their own. For \n149 those who were extremely ill or injured upon initial presentation, the research team re-evaluated \n150 the patient within 24 hours of arriving at KCMC or before discharge, whichever came first. \n151 Those who remained unable to consent within this time frame were excluded from study \n152 participation. As this study was also conducted relatively early in the COVID-19 pandemic, for \n153 the safety of the data collection team, patients who tested positive for COVID-19 were also not \n154 approached. No women participants presented to both the ED and RHC.\n155 Procedures\n156 All data were collected in the local language of KiSwahili by a team of three Tanzanian \n157 research assistants (two women and one man) who had been hired specifically for work on this \n158 study. The final team was chosen based on their expertise in research and strong interpersonal \n159 and leadership skills. \n160 For data collection, the male research assistant surveyed and interviewed all men \n161 participants, and the two female research assistants surveyed and interviewed all women \n162 participants. This gender-matching between research assistants and interviewees was done to \n163 encourage open and honest reporting of patients’ experiences with or opinions on alcohol based \n164 on local culture and research team experience. (33) Prior to data collection, thorough instruction \n165 on Good Clinical Practices and extensive study-specific training was provided to the Tanzanian \n166 team, including an overview of qualitative data collection methods. All members of the \n167 Tanzanian research team were fluent in both English and KiSwahili and held a college degree or \n168 higher. The Tanzanian research team held a diverse set of competencies that promoted the \n169 collection of robust and reliable data, such as clinical nursing skills and numerous years of \n170 previous research experience, including within the field of alcohol-related research specifically.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n10\n171 Quantitative Data\n172 Sample Size Calculations\n173 During the initial study design, it was hypothesized that a final sample size of 587 \n174 subjects would be required to determine if a significant difference in the prevalence of risky \n175 drinking, defined as a score of 8 or greater on the Alcohol Use Disorder Identification Test \n176 (AUDIT) scores exists between a) men and women KCMC Emergency Department (ED) \n177 patients and b) women patients at the KCMC ED and KCMC Reproductive Health Center (RHC) \n178 ( Table 1). From the Emergency Department, 94 participants (47 men and 47 women) were \n179 surveyed to compare across genders the proportion of those who screen positively for risky \n180 drinking behavior with 80% power and 90% confidence. Likewise, 540 female participants (270 \n181 from the ED and 270 from the RHC) were surveyed to compare the prevalence of those who \n182 were positive for risky drinking behavior between these two units with 80% power and 90% \n183 confidence. The final sample size was 587, as survey score data collected from female ED \n184 patients were used in both analyses.\n185 Table 1: Initial Sample Size Calculations\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n11\n186 However, as of early December 2021, two months into the eight-month data collection \n187 timeline, the proportion of AUDIT scores ≥ 8 among ED patients was approximately 40% for \n188 women and 45% for men, a difference of only 5% as compared to 15% difference upon which \n189 the original sample size calculations were based. This meant that to maintain 90% confidence \n190 and 80% power, 1,200 patients would need to be enrolled to determine the difference in \n191 proportions. While study funds and the data collection timeline limited this doubling in sample \n192 size, with IRB amendment approval, the study’s targeted enrollment goals were increased based \n193 on the re-estimated prevalence. Thus, enrolling as many patients as was feasible within the \n194 original logistical study bounds resulted in a total of 655 total participants by the conclusion of \n195 this study timeline.\n196 Procedures\n197 To collect as representative of a sample as possible in the ED and RHC, a systematic \n198 sampling method was employed. Patients seeking care at KCMC’s EMD or RHC were enrolled \n199 Monday through Friday from 10:00 am until 6:00 pm local time, with the exception of Tanzanian \n200 holidays. While enrollment of women patients was consistent throughout the entire data \n201 collection period, enrollment of men patients was paused from January 1st, 2021, until March \n202 31st, 2022, pending expanded sample size regulatory approvals.\n203 Within the RHC, which sees a large daily volume of women patients, every third patient \n204 listed on the general intake registry log was approached and offered study participation. Given \n205 the nature of RHC care which often requires follow-up visits, a month into data collection, \n206 approximately a fifth of the daily RHC patient population had already been approached for study \n207 participation. As such, when sampling individuals from the intake registry, if a woman had \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n12\n208 previously been asked about study participation, her name was skipped and every third patient \n209 starting from the following individual was approached. \n210 At the ED, which sees significantly fewer women patients than men patients, every \n211 woman, but every 3rd man on the triage registry was approached. This was done to maintain \n212 planned enrollment goals and a representative, systematic random sampling of patients. Each of \n213 the three research assistants primarily enrolled one patient population (ED men, ED women, and \n214 RHC women). Halfway through data collection (once 135 women patients from both the ED and \n215 RHC had been collected), the two women research assistants switched clinical units to minimize \n216 any bias that may have arisen as a result of differences in their style of patient interaction or \n217 information extraction.\n218 Patients were only approached once, and all were given the option to decline participation \n219 or terminate their participation early if they chose. All patients were approached in a quiet, \n220 private location only once medically stabilized. Here, an overview of the study, including the \n221 study goals, procedures, potential risks, and benefits was explained. If, after this discussion, the \n222 patient was willing to participate, written consent was obtained. Surveys were administered \n223 orally by the same-gender research assistants so that patients of all literacy levels were able to \n224 participate and the responses were recorded into a secure Research Electronic Data Capture \n225 (REDCap) database. As surveys were collected at a single time point, there were no patients lost \n226 to follow-up. In rare instances where survey collection was interrupted, some surveys were left \n227 incomplete (n = 23). Incomplete surveys were included in analyses but were not counted as part \n228 of the final sample needed for determining differences in prevalence.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n13\n229 Instruments\n230 Quantitative surveys consisted of five main components: (1) basic demographic data, (2) \n231 self-reported alcohol use data, (3) the Alcohol Use Disorder Identification Test (AUDIT), (4) the \n232 Drinkers’ Inventory of Consequences (DrInC), and (5) the depression module of the Patient \n233 Health Questionnaire (PHQ-9). AUDIT, which ranges from 0 to 40, is a commonly used survey \n234 tool for measuring alcohol consumption and alcohol-related problems (34,35). Both locally and \n235 globally, patients scoring greater than or equal to 8 are earmarked as clinically significant for \n236 harmful or hazardous drinking (HHD) (35–39). Patients with HHD represent individuals whose \n237 alcohol intake is detrimental to their physical well-being and require further alcohol-related \n238 clinical care and support (40). As such, the prevalence of HHD (defined as AUDIT ≥ 8) was a \n239 primary cut-off point in this analysis. DrInC is a 50-question survey (with possible scores \n240 ranging from 0 to 50) that measures alcohol-related consequences: in particular, interpersonal, \n241 intrapersonal, social responsibility, impulse control, and physical consequences (41). While there \n242 is no clinically significant cut-off score, higher scores indicate greater consequences for an \n243 individual (42). Finally, PHQ-9 is a diagnostic tool used to identify the existence and severity of \n244 depression (43). This scale ranges from 0 to 27, with higher values suggesting increasingly \n245 severe depressive symptoms. In the KiSwahili-translated version of the PHQ-9, scores of 9 or \n246 greater were found to be the optimal cut-off score for identifying clinical depression (44) and \n247 thus was the cut-off point used in this analysis. All three scales had previously been cross-\n248 culturally adapted, psychometrically validated, and clinically tested in the local context \n249 (39,44,45). \n250 All non-survey tool questions were reviewed, revised, translated, and pilot tested by the \n251 Tanzanian research team prior to data collection. As this analysis focuses specifically on \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n14\n252 patients’ alcohol consumption, DrInC and PHQ-9 scores were not included in this manuscript but \n253 will be analyzed in later work. Of note, while this study focuses on gender differences, patients \n254 self-identified according to their biological sex. Given that there is little reported gender diversity \n255 in Tanzania, for the purposes of this analysis, those identifying as men were categorized as male, \n256 and those identifying as women were categorized as female.\n257 Analysis\n258 Gender differences in alcohol consumption and alcohol-related problems were assessed \n259 quantitatively through an exploratory analysis of AUDIT scores, the prevalence of HHD, and \n260 demographic and self-reported alcohol consumption data.  Consumption was also measured \n261 through self-reported alcohol consumption questions that asked participants how much and how \n262 often they consumed alcohol, what types of alcohol they preferred, and how much money they \n263 typically spent on alcohol per week. All data were analyzed using descriptive frequencies and \n264 proportions, and all variables were categorical with the exception of AUDIT scores and HHD \n265 status. As alluded to above, AUDIT scores were dichotomized according to HHD status; scores \n266 of 8 or greater were classified as ‘HHD,’ while scores less than 8 were ‘not HHD’. Except for \n267 age, measures of income, and educational attainment, missing data were minimal for all variables \n268 analyzed. The age question was mistakenly omitted in the first several surveys and was added a \n269 week into data collection, however for income and educational attainment, participants were \n270 more hesitant to disclose this information to research staff.\n271 Unlike the qualitative data, all quantitative data were compared across three groups: ED \n272 women, ED men, and RHC women rather than by gender alone. This was done to a) identify \n273 which clinical unit had the highest incidence of unhealthy alcohol users and b) provide more \n274 accurate descriptions of the two women patient populations as the RHC and ED women \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n15\n275 populations held significantly distinct demographic and alcohol use-related characteristics. All \n276 statistical analyses were conducted in RStudio (version 1.4) using user-created and validated R-\n277 Packages.\n278 Qualitative Data\n279 Sample Size Calculations\n280 Of all participants who completed the quantitative survey, a small subset was selected for \n281 participation in semi-structured IDIs. 20 (or until saturation was reached) IDIs were originally \n282 anticipated to be collected, 10 from ED men patients, 5 from ED women patients, and 5 from \n283 RHC women patients to facilitate gender-balanced perspectives on alcohol use. The men ED \n284 population reached saturation (defined as the absence of new themes and information following \n285 three consecutive interviews) in 9 interviews, thus, 19 IDIs in total were completed. \n286 Procedures\n287 IDIs were used in this study given the highly sensitive and stigmatizing nature of the \n288 study topic, especially for women participants. The one-on-one interview structure encouraged \n289 women in particular to share their thoughts more freely and helped to ensure their privacy and \n290 confidentiality. IDI procedures were first initiated during survey collection. At the time of the \n291 quantitative survey, if a research assistant identified an individual whom they thought would be \n292 an excellent candidate for an IDI, they asked if the subject would be willing to participate in an \n293 IDI. Those who were invited were purposefully chosen to encompass a diverse range of \n294 demographic backgrounds (including age, marital status, education level and occupation, tribe, \n295 and religion), perspectives on, and personal experiences with alcohol. IDI participants were also \n296 selected to speak to trends related to risky drinking that arose from preliminary quantitative \n297 findings. One example of this is that women who were either divorced or widowed were \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n16\n298 associated with above-average alcohol intake early on in the data collection period. \n299 Subsequently, a woman who had been recently divorced and had a high alcohol intake was \n300 purposefully asked to participate in an IDI. To ensure diverse representation and minimize any \n301 unintentional bias in sampling, the characteristics of IDI participants were reviewed monthly by \n302 the study lead, and any needed changes in the subject sampling were implemented at the next IDI \n303 selection.\n304 If agreeing, the research assistant obtained the patients’ phone numbers with their consent \n305 and scheduled a later time to meet. All interviews were held in private rooms within KCMC and \n306 were conducted by a same-gender interviewer who had an established relationship with the \n307 patient as they had previously spoken with the patient in-depth during survey collection. The \n308 goals of the research study were communicated again before interviews commenced, and a small \n309 fund of 5,000 TSH (~2 USD) was given to participants as a transportation reimbursement. All \n310 interviews were audio-recorded and generally lasted from 60 to 100 minutes, with a break and \n311 snacks offered midway through.\n312 Instruments\n313 As with the surveys, all interview questions were created in English and then translated \n314 into KiSwahili. These translations were then reviewed for appropriate phrasing and syntax, \n315 subsequently revised, and then pilot tested by the Tanzanian research team to ensure cultural \n316 appropriateness, relevancy, and retention of the original meaning. The interview guide consisted \n317 of open-ended questions with built-in probes. Additional probing questions were added on a \n318 case-by-case basis by the Tanzanian research team if a participant said something unclear, \n319 contradictory, or warranted further explanation. The guide was developed using a team-based \n320 approach and was structured and organized across the 6 following domains: (1) effect on and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n17\n321 expectations of the community, (2) men’s use, (3) women’s use, (4) gender differences in use, \n322 (5) use during pregnancy, and (6) recommendations for future interventions. The qualitative data \n323 in this manuscript pulls primarily from domains 2 through 4, to specifically explore how gender \n324 impacts alcohol consumption and use behaviors. Important themes regarding alcohol use and \n325 depression arose from the first seven interviews, so several questions related to these concepts \n326 were added at this point and were included in all following interviews. With the exception of this \n327 addition, the guide remained the same for all interviews.\n328 Analysis\n329 IDIs were analyzed using an applied thematic, grounded theory approach. (46) As female \n330 drinking behaviors in this region have received little prior research attention, a grounded theory \n331 approach was best suited for this study as it allowed new themes to arise and be sufficiently \n332 explored. A codebook, which was only accessible to the qualitative research team, was \n333 developed by the main data analyst based on the first four 4 interviews following a mix of \n334 deductive and inductive coding schemes. The initial codebook was discussed with all members \n335 of the Tanzanian research team, and changes were made based on the received feedback, \n336 ensuring content validity and cultural accuracy. The codebook was used as a dynamic document \n337 and was updated as new themes emerged from the data. After revisions to the codebook were \n338 made, previous transcripts were revisited and recoded if necessary to encompass newly identified \n339 themes that emerged.\n340 In partnership with the main analyst, the Tanzanian research team was trained on \n341 qualitative analysis and interview coding using NVivo 12. The initial interviews were \n342 independently coded in four separate documents by the main analyst and the three members of \n343 the Tanzanian research team. These documents were then compared to establish an agreement on \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n18\n344 the coding strategy and codebook development. When disagreement arose between researchers, \n345 the research team discussed the codes in question until a consensus was reached. This process \n346 was repeated until 80% agreement was obtained (47) among the four analysts which occurred \n347 after three interviews were coded and reviewed. After a high rate of internal consistency in \n348 coding was obtained amongst the 4 initial coders, the primary analyst used the final codebook to \n349 code the remaining 16 interviews. The final coding was approved by the analysis team. Content \n350 memos were created per each emerging theme and code, summarizing the findings in an ongoing \n351 fashion. The content memos served as a basis for discussion and feedback to the entire research \n352 team.\n353 Research Ethics\n354 Prior to data collection, ethical approval was obtained from the Duke University \n355 Institutional Review Board, the Kilimanjaro Christian Medical University College Ethical \n356 Review Board, and the Tanzanian National Institute of Medical Research. As much as possible, \n357 data was maintained in a de-identified manner and shared by data share agreement. Personal \n358 health information was used for screening and enrollment, but data were collected, stored, and \n359 analyzed in a de-identified manner.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n19\n360 Results\n361 Quantitative\n362 Between October 11th, 2021, and May 31st, 2022, all eligible patients present during \n363 study hours were approached, with 655 patients (Table 2) completing the surveys. Few \n364 individuals declined study participation; however, as reported by the Tanzanian research team, \n365 women were more likely than men to do so, with the primary reasons being that (a) they did not \n366 wish to discuss their alcohol use and (b) concern for their privacy.\n367 Following the enrollment goals for each of the three patient populations, this study \n368 sample was composed primarily of women (82.6%). Most participants were also Christian \n369 (80%), employed (57%), and living with a partner either in a registered (50%) or unregistered \n370 (12%) marriage. RHC women had the greatest proportion of young patients, with 37% being \n371 between the ages of 25 and 34. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n20\n372 Table 2: Study Population Demographics\nDemographics by Population Type Overall, \nN = 6551\nED Women, \nN = 2711\nRHC Women, \nN = 2701\nED Men, \nN = 1141\nAge Category, missing: 49\n18 to 24 110 / 606 (18%) 47 / 252 (19%) 53 / 249 (21%) 10 / 105 (9.5%)\n25 to 34 159 / 606 (26%) 41 / 252 (16%) 92 / 249 (37%) 26 / 105 (25%)\n35 to 44 106 / 606 (17%) 42 / 252 (17%) 45 / 249 (18%) 19 / 105 (18%)\n44 to 54 94 / 606 (16%) 47 / 252 (19%) 32 / 249 (13%) 15 / 105 (14%)\nOver 55 137 / 606 (23%) 75 / 252 (30%) 27 / 249 (11%) 35 / 105 (33%)\nPersonal Income Category (TZS per month), missing: 11\n0 to 50,000 205 / 644 (32%) 110 / 270 (41%) 68 / 268 (25%) 27 / 106 (25%)\n50,001 to 100,000 44 / 644 (6.8% 17 / 270 (6.3%) 15 / 268 (5.6%) 12 / 106 (11%)\n100,001 to 150,000 56 / 644 (8.7%) 17 / 270 (6.3%) 29 / 268 (11%) 10 / 106 (9.4%)\n150,001 to 200,000 91 / 644 (14%) 34 / 270 (13%) 37 / 268 (14%) 20 / 106 (19%)\n> 200,000 248 / 644 (39%) 92 / 270 (34%) 119 / 268 (44%) 37 / 106 (35%)\nHousehold Income Category (TZS per month), missing: 11\n0 to 50,000 62 / 644 (9.6%) 33 / 271 (12%) 16 / 267 (6.0%) 13 / 106 (12%)\n50,001 to 100,000 47 / 644 (7.3%) 17 / 271 (6.3%) 14 / 267 (5.2%) 16 / 106 (15%)\n100,001 to 150,000 74 / 644 (11%) 32 / 271 (12%) 31 / 267 (12%) 11 / 106 (10%)\n150,001 to 200,000 72 / 644 (11%) 37 / 271 (14%) 20 / 267 (7.5%) 15 / 106 (14%)\n> 200,000 389 / 644 (60%) 152 / 271 (56%) 186 / 267 (70%) 51 / 106 (48%)\nReligion\nChristian 522 / 655 (80%) 218 / 271 (80%) 222 / 270 (82%) 82 / 114 (72%)\nMuslim 121 / 655 (18%) 47 / 271 (17%) 45 / 270 (17%) 29 / 114 (25%)\nNone 11 / 655 (1.7%) 5 / 271 (1.8%) 3 / 270 (1.1%) 3 / 114 (2.6%)\nOther 1 / 655 (0.2%) 1 / 271 (0.4%) 0 / 270 (0%) 0 / 114 (0%)\nHighest Educational Attainment, missing: 60\nCollege 170 / 595 (29%) 65 / 242 (27%) 87 / 241 (36%) 18 / 112 (16%)\nGraduate 13 / 595 (2.2%) 4 / 242 (1.7%) 2 / 241 (0.8%) 7 / 112 (6.2%)\nNone 52 / 595 (8.7%) 30 / 242 (12%) 7 / 241 (2.9%) 15 / 112 (13%)\nPrimary 182 / 595 (31%) 82 / 242 (34%) 61 / 241 (25%) 39 / 112 (35%)\nSecondary 133 / 595 (22%) 48 / 242 (20%) 64 / 241 (27%) 21 / 112 (19%)\nVocational 45 / 595 (7.6%) 13 / 242 (5.4%) 20 / 241 (8.3%) 12 / 112 (11%)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n21\nDemographics by Population Type Overall, \nN = 6551\nED Women, \nN = 2711\nRHC Women, \nN = 2701\nED Men, \nN = 1141\nMarital Status, missing: 1\nDivorced or Separated 31 / 654 (4.7%) 16 / 271 (5.9%) 6 / 270 (2.2%) 9 / 113 (8.0%)\nLiving with a partner, not in a registered marriage 79 / 654 (12%) 26 / 271 (9.6%) 41 / 270 (15%) 12 / 113 (11%)\nLiving with a partner in a registered marriage 327 / 654 (50%) 128 / 271 (47%) 140 / 270 (52%) 59 / 113 (52%)\nNever Married or Single 135 / 654 (21%) 55 / 271 (20%) 56 / 270 (21%) 24 / 113 (21%)\nRefused/Do not know 1 / 654 (0.2%) 0 / 271 (0%) 0 / 270 (0%) 1 / 113 (0.9%)\nWidowed 81 / 654 (12%) 46 / 271 (17%) 27 / 270 (10%) 8 / 113 (7.1%)\nEmployment Status\nEmployed 371 / 655 (57%) 127 / 271 (47%) 192 / 270 (71%) 52 / 114 (46%)\nUnemployed 215 / 655 (33%) 111 / 271 (41%) 50 / 270 (19%) 54 / 114 (47%)\nStudent 69 / 655 (11%) 33 / 271 (12%) 28 / 270 (10%) 8 / 114 (7.0%)\nTribe\nChagga 329 / 655 (50%) 126 / 271 (46%) 146 / 270 (54%) 57 / 114 (50%)\nIraq 21 / 655 (3.2%) 9 / 271 (3.3%) 8 / 270 (3.0%) 4 / 114 (3.5%)\nMaasai 25 / 655 (3.8%) 13 / 271 (4.8%) 7 / 270 (2.6%) 5 / 114 (4.4%)\nMmeru 29 / 655 (4.4%) 14 / 271 (5.2%) 11 / 270 (4.1%) 4 / 114 (3.5%)\nMuha or Non-African 6 / 655 (1.0%) 3 / 271 (1.1%) 3 / 270 (1.1%) 0 / 114 (0%)\nNyaturu 17 / 655 (2.6%) 7 / 271 (2.6%) 10 / 270 (3.7%) 0 / 114 (0%)\nOther African 98 / 655 (15%) 55 / 271 (20%) 34 / 270 (13%) 9 / 114 (7.9%)\nPare 70 / 655 (11%) 27 / 271 (10.0%) 25 / 270 (9.3%) 18 / 114 (16%)\nSambaa 26 / 655 (4.0%) 7 / 271 (2.6%) 10 / 270 (3.7%) 9 / 114 (7.9%)\nSukuma 34 / 655 (5.2%) 10 / 271 (3.7%) 16 / 270 (5.9%) 8 / 114 (7.0%)\n1n / N (%); Mean (SD)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n22\n374 Across the three patient populations, the highest average [SD] AUDIT scores belonged to \n375 ED men (6.76 [8.16]), followed by ED women (3.07 [4.76]), and RHC women (1.86 [3.46]) \n376 (Table 3). ED men also had the highest prevalence of HHD (38%) across all patients, although a \n377 significant percentage of ED women (17%) still had AUDIT scores ≥ 8 (Table 3; Figure 3). RHC \n378 women had the lowest percentage of individuals with HHD (7.4%) across the three groups \n379 (Table 3; Figure 3). \n380 In other markers of alcohol use, men continued to score above both women populations. \n381 ED men spent the most money on alcohol per week (4.4% of ED men, 0.7% of ED women, and \n382 0.4% of RHC women spent between 50,001 to 1000,000 TZS per week), drank in the largest \n383 quantities (4.4% of ED men, 0.4% of ED women, and 0% of RHC women drank more than 6 \n384 standard drinks per sitting), and drank the most frequently (3.5% of ED men drank multiple \n385 times per day, but neither ED nor RHC women reported drinking more than daily). Interestingly, \n386 while men consumed the most, ED men and ED women answered affirmatively that they have \n387 attempted to quit drinking previously in roughly equal (51% for women and 52% for men) \n388 proportions, and men were also the most likely (89%) to believe that alcohol use was unhealthy \n389 (compared to 71% among ED women and 65% among RHC women). \n390 While men had the highest rates of consumption, unhealthy alcohol users were present \n391 among both women patient populations. For example, 3.0% and 1.1%, of ED and RHC women, \n392 respectively, consumed 5 or more standard drinks in a sitting, and 3.7% of ED women and 1.1% \n393 of RHC women reported drinking alcohol every day.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n23\n394 Table 3: Alcohol Use Characteristics\nAlcohol Use Characteristics by \nPopulation Type\nOverall, \nN = 6551\nED Women, \nN = 2711\nRHC Women, \nN = 2701\nED Men, \nN = 1141\nAlcohol Preferences\nBeer 136 / 655 (21%) 66 / 271 (24%) 41 / 270 (15%) 29 / 114 (25%)\nChangaa, Dadii, Gongo, or Piwa 8 / 655 (1.2%) 5 / 271 (1.8%) 0 / 270 (0%) 3 / 114 (2.6%)\nLight Beer 60 / 655 (9.2%) 20 / 271 (7.4%) 21 / 270 (7.8%) 19 / 114 (17%)\nLiquor/Spirits 12 / 655 (1.8%) 3 / 271 (1.1%) 1 / 270 (0.4%) 8 / 114 (7.0%)\nMbege (banana-based beer) 83 / 655 (13%) 43 / 271 (16%) 24 / 270 (8.9%) 16 / 114 (14%)\nUlanzi (bamboo-based liquor) 5 / 655 (0.8%) 2 / 271 (0.7%) 1 / 270 (0.4%) 2 / 114 (1.8%)\nWine 85 / 655 (13%) 30 / 271 (11%) 38 / 270 (14%) 17 / 114 (15%)\nNone 258 / 655 (39%) 100 / 271 (37%) 143 / 270 (53%) 15 / 114 (13%)\nOther/Refused/Do not know 8 / 655 (1.2%) 2 / 271 (0.7%) 1 / 270 (0.4%) 5 / 114 (4.4%)\nDrinking Frequency, missing: 2\n0 times/week 269 / 653 (41%) 101 / 271 (37%) 146 / 269 (54%) 22 / 113 (19%)\n1-2 times/week 289 / 653 (44%) 130 / 271 (48%) 100 / 269 (37%) 59 / 113 (52%)\n3-4 times/week 66 / 653 (10%) 28 / 271 (10%) 17 / 269 (6.3%) 21 / 113 (19%)\n5-6 times/week 6 / 653 (0.9%) 2 / 271 (0.7%) 2 / 269 (0.7%) 2 / 113 (1.8%)\nEvery day 17 / 653 (2.6%) 10 / 271 (3.7%) 3 / 269 (1.1%) 4 / 113 (3.5%)\nMultiple times a day 4 / 653 (0.6%) 0 / 271 (0%) 0 / 269 (0%) 4 / 113 (3.5%)\nRefused/Do not know 2 / 653 (0.3%) 0 / 271 (0%) 1 / 269 (0.4%) 1 / 113 (0.9%)\nDrinking Quantity, missing: 1\n0 drinks 268 / 654 (41%) 102 / 271 (38%) 145 / 270 (54%) 21 / 113 (19%)\n1-2 bottles 264 / 654 (40%) 119 / 271 (44%) 87 / 270 (32%) 58 / 113 (51%)\n3-4 bottles 97 / 654 (15%) 42 / 271 (15%) 34 / 270 (13%) 21 / 113 (19%)\n5-6 bottles 16 / 654 (2.4%) 7 / 271 (2.6%) 3 / 270 (1.1%) 6 / 113 (5.3%)\n>6 bottles 6 / 654 (0.9%) 1 / 271 (0.4%) 0 / 270 (0%) 5 / 113 (4.4%)\nRefused/Do not know 3 / 654 (0.5%) 0 / 271 (0%) 1 / 270 (0.4%) 2 / 113 (1.8%)\nWeekly Alcohol Expenses (TZS), missing: 1\n0-10000 531 / 654 (81%) 228 / 271 (84%) 238 / 270 (88%) 65 / 113 (58%)\n10001-50000 110 / 654 (17%) 41 / 271 (15%) 29 / 270 (11%) 40 / 113 (35%)\n50001-100000 8 / 654 (1.2%) 2 / 271 (0.7%) 1 / 270 (0.4%) 5 / 113 (4.4%)\nRefused/Do not know 5 / 654 (0.8%) 0 / 271 (0%) 2 / 270 (0.7%) 3 / 113 (2.7%)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n24\nAlcohol Use Characteristics by \nPopulation Type\nOverall, \nN = 6551\nED Women, \nN = 2711\nRHC Women, \nN = 2701\nED Men, \nN = 1141\nAttempted Quitting, missing: 1\nNo 340 / 654 (52%) 132 / 270 (49%) 166 / 270 (61%) 42 / 114 (37%)\nRefused/Do not know 16 / 654 (2.4%) 1 / 270 (0.4%) 2 / 270 (0.7%) 13 / 114 (11%)\nYes 298 / 654 (46%) 137 / 270 (51%) 102 / 270 (38%) 59 / 114 (52%)\nReason for Quitting for the 298 patients who Attempted:\nFamily 17 / 298 (5.7%) 9 / 137 (6.6%) 3 / 102 (2.9%) 5 / 59 (8.5%)\nFinancial 24 / 298 (8.1%) 7 / 137 (5.1%) 4 / 102 (3.9%) 13 / 59 (22%)\nHealth 105 / 298 (35%) 52 / 137 (38%) 37 / 102 (36%) 16 / 59 (27%)\nOther 1 / 298 (0.3%) 1 / 137 (0.7%) 0 / 102 (0%) 0 / 59 (0%)\nPersonal 128 / 298 (43%) 60 / 137 (44%) 49 / 102 (48%) 19 / 59 (32%)\nSpiritual 23 / 298 (7.7%) 8 / 137 (5.8%) 9 / 102 (8.8%) 6 / 59 (10%)\nAlcohol Use perceived as Unhealthy, missing: 1\nNo 179 / 654 (27%) 74 / 270 (27%) 92 / 270 (34%) 13 / 114 (11%)\nRefused/Do not know 7 / 654 (1.1%) 4 / 270 (1.5%) 3 / 270 (1.1%) 0 / 114 (0%)\nYes 468 / 654 (72%) 192 / 270 (71%) 175 / 270 (65%) 101 / 114 (89%)\nSought Treatment for Alcohol Use, missing: 3\nNo 606 / 652 (93%) 251 / 269 (93%) 260 / 269 (97%) 95 / 114 (83%)\nRefused/Do not know 1 / 652 (0.2%) 1 / 269 (0.4%) 0 / 269 (0%) 0 / 114 (0%)\nYes 45 / 652 (6.9%) 17 / 269 (6.3%) 9 / 269 (3.3%) 19 / 114 (17%)\nSought Psychiatric Treatment, missing: 2\nNo 592 / 653 (91%) 245 / 270 (91%) 242 / 270 (90%) 105 / 113 (93%)\nRefused/Do not know 2 / 653 (0.3%) 1 / 270 (0.4%) 1 / 270 (0.4%) 0 / 113 (0%)\nYes 59 / 653 (9.0%) 24 / 270 (8.9%) 27 / 270 (10%) 8 / 113 (7.1%)\nAUDIT Score 3.22 (5.36) 3.07 (4.76) 1.86 (3.46) 6.76 (8.16)\nHHD Status (AUDIT >= 8) 109 / 655 (17%) 46 / 271 (17%) 20 / 270 (7.4%) 43 / 114 (38%)\n1n / N (%); Mean (SD)\n396\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n25\n397 Figure 2: Comparison of AUDIT Score Distributions across Patient Populations\n398\n399\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n26\n400 Figure 3: Prevalence of Harmful/Hazardous Drinking (HHD) Across Patient Populations\n401\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n27\n402 Qualitative \n403 Of the 655 individuals surveyed, 19 individuals (RHC women, n = 5; ED women, n = 5; \n404 ED men, n = 9) participated in an IDI. Most IDI participants were Christian (78.9%), their ages \n405 ranged from 20 to 70 years, and they held a variety of education levels that stretched from \n406 primary education to a college degree. Almost half (9 out of 19) of the respondents were living \n407 with a partner in a registered marriage at the time of the interview, five were never married, two \n408 were divorced or separated, two were living with a partner in an unregistered marriage, and one \n409 was widowed. Only one participant was pregnant at the time of the interview, and five \n410 participants did not consume alcohol regularly. The intake of the other respondents ranged from \n411 1 to 2 bottles 1 to 2 times per week to 3 to 4 bottles 5 to 6 times per week.\n412 Alcohol use behaviors differed between men and women across all major themes (how, \n413 why, when, where, and what) assessed (Table 4). In general, respondents reported that men had \n414 greater agency around their drinking, meaning greater ability and access to control their own \n415 drinking behaviors. They also drank more publicly, and in greater quantities with higher alcohol-\n416 content drinks. For men, alcohol use was encouraged in social situations and was influenced by \n417 the potential for gaining social power or despair over lack of life opportunity. In comparison, IDI \n418 participants remarked that most women drank less, consumed lighter beers and wines, and were \n419 more restricted as to where and when it was acceptable for them to drink. This restriction was in \n420 part because of traditional gender roles keeping women more closely tied to the home and family \n421 life, and also the concern for them to incur physical harm while drinking. For women, motives to \n422 drink were most closely tied to relationship stress and social pressure.\n423\n424 Table 4: IDI Alcohol Consumption Themes and Subthemes\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n28\nThemes Sub-themes\nHow Consumption Differs Men consume larger quantities of alcohol\nTraditional gender roles impact alcohol consumption\nMale drinking is more culturally normalized  \nMotivations to Drink Relationship stress\nLack of opportunity\nSocial pressure\nSocial power\nWhen Alcohol Intake \nOccurs\nThe best time to drink is after completing daily tasks\nWomen with families are too busy with household tasks to drink\nWomen with families are encouraged to drink after her kids are \nasleep\nWhere Alcohol Intake \nOccurs\nMen drink in public locations to socialize with others\nPublic drinking for women creates a risk physical harm\nWomen drink privately to avoid social stigma\nWhat Types of Alcohol is \nConsumed\nAbility of Alcohol to Intoxicate the Drinker\nSocial clout\nWealth and socioeconomic status\n425\n426 How Use Differs by Gender\n427 When asked how alcohol use differs between men and women, most IDI participants \n428 reported that men drank more than women, a trend that was facilitated by men having greater \n429 agency to drink, and men’s drinking being more culturally normalized. \n430 Overwhelmingly, respondents agreed that “alcohol use among men is high compared to \n431 women” (IDI #12, Male), but with the caveat that especially in recent years, this has been \n432 changing; “sometimes women drink more alcohol than men. This is because women have [more] \n433 economical power than men nowadays, so are the ones that ruling the world.” (IDI #5, Male)\n434 Even still, for most, pre-existing community and familial norms appeared to limit \n435 women’s alcohol consumption in comparison to men. Traditional gender roles meant that men \n436 had greater freedom to drink alcohol, as explained in IDI #16.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n29\n437\n438 “Women are obliged to stay at home for a long time for the nurturing and taking care of \n439 children and family at large, so it’s not easy for a woman to find time every day to go out \n440 with friends to drink alcohol…After [men] come out of job they don’t have a lot to do at \n441 home like taking care of kids, they leave that all to women and mostly they instead go out \n442 with friends to drink…when a man comes from work he can pass by home and see the \n443 family leave some money and off he goes to have a drink outside…men have an ample \n444 time to relax, enjoy and that’s when they get to drink alcohol.” – IDI #16, Female\n445\n446 This sentiment was taken one step further by several male respondents who suggested \n447 that because of these responsibilities, some women are denied the option to drink at all; “Woman \n448 are not even allowed to drink …because they get drunk easily and, once drunk, they will not be \n449 able to do home chores” while “men drink more than women because they are free and have \n450 money, so they can buy alcohol whenever they want” (IDI #2, Male). As illustrated by these \n451 quotes, in comparison to men, women appeared to lack control over their ability to drink. This \n452 lack of agency is also confounded by having fewer funds, less free time, and more intensive \n453 home responsibilities. \n454 In alignment with men’s alcohol intake being higher, there were more examples of men \n455 who displayed dependent or problematic drinking behaviors – men who “can’t be okay without \n456 drinking” (IDI #1, Female). Moreso, these examples were largely normalized – drinking “too \n457 much… seems normal in the community” (IDI #1, Female). One woman said:\n458\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n30\n459  “[Men] drink alcohol as routine and it has now become compulsory for some of them to \n460 take a drink everyday of their life to complete their daily activities. For example, the men \n461 with heavy physical jobs but even doctors and businessmen also take alcohol every \n462 morning before going to work. I have witnessed a man who wouldn’t go to his workplace \n463 before drinking because otherwise his hands would be shaking and he cannot touch \n464 anything and that’s his routine...He was a doctor back in the village I was living.” – IDI \n465 #3, Female\n466 Motivations to Drink\n467 Among men and women, stress was the leading factor in alcohol initiation and \n468 progression into unhealthy drinking habits. This was followed by social pressure, and for men, \n469 social power. It is important to note that these factors are often intertwined within interviews, for \n470 example, social pressures could be seen as a form of relationship stress, and relationship stress is \n471 a form of social pressure. \n472 Speaking first to stress, many respondents agreed that “most people drink alcohol in the \n473 community due to stress…alcohol is no longer considered as a refreshing drink, rather than a \n474 stress remover substance!” (IDI #5, Male). The causes of stress usually stemmed from conflicts \n475 in relationships – “in town people drink too much because of stress related to love affairs, you \n476 find that there is conflict between them, especially cheating; this lead to excessive alcohol use to \n477 relieve the stress” (IDI #4, Male) – or financial strain – “life has become so difficult, and people \n478 cannot afford life expenses” (IDI #5, Male).\n479 For women especially, conflicts in relationships arose as a significant stressor and reason \n480 for alcohol initiation.\n481\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n31\n482 “Where I live so many women live with stress because of being abandoned by men or men \n483 are there but they don't take care of the family…something which leads a lot of women to \n484 drinking too much alcohol every day…myself I have lived well with my husband but after \n485 a long illness he has run away from home and he has left me no money. If I didn't know \n486 God and hold onto him, I could end up drinking too much alcohol because of stress until \n487 I die” (IDI #13, Female)\n488\n489 Another individual reported,\n490\n491 “women drink alcohol to reduce stress when she has arguments with her husband, she \n492 decides to drink too much alcohol so that when she comes home, she will not talk to her \n493 husband anymore she will only fall to sleep.” (IDI #6, Female)\n494\n495 The theme of relationship stress was present for males as well, but was not as strong of a \n496 factor as it was for females. IDI #7, Female, said “when one has misunderstanding with his wife, \n497 he can get drunk to relieve the anger.”\n498 Limited career opportunities that led to financial stress and subsequent poor coping \n499 strategies, on the other hand, facilitated problematic drinking behaviors primarily among men. \n500 This disproportionate effect is in part because men are traditionally seen as the economic \n501 providers in Tanzanian culture. \n502\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n32\n503 “Most young men drink too much alcohol…because they don’t have any future about \n504 their life. This is associated with lack of employment, people finishing school but there is \n505 not a job to do which makes them frustrated.” (IDI #8, Male)\n506\n507 A lack of professional opportunity seemed to impact young and older men alike; another \n508 participant, IDI #2, a middle-aged male, noted that the previous year he was “preoccupied with a \n509 lot of stress” as his tourist company was “not doing well” and his “mom was sick, and there was \n510 no money to take care of her.” These stressors led him and other men to drink–what he described \n511 as “a poor coping strategy” (IDI #2, Male) – “men drink more than women because they have \n512 stress and depression about life challenges” (IDI #8, Male). One participant postulated that men \n513 relied on alcohol to relieve stress more than women did because\n514\n515 “They don’t want to speak about things which troubles them, they take out their \n516 problems through drinking alcohol...Men think when they talk about their problems it is \n517 a sign of weakness” (IDI #15, Female)\n518\n519 Social pressure was another key factor driving alcohol use. For women, social pressures \n520 included peer pressure from social circles, engaging in drinking behaviors with their husbands, \n521 and using alcohol to obtain confidence in social situations. For example, one respondent said “it \n522 is [unusual] to find a women drink when the husband doesn’t” (IDI #12, Male). This was \n523 expounded upon by another participant, “women drinks when their men drink as well, or \n524 sometimes they drink because of peer pressure or company…[they] drink because they want to \n525 relax, to gain confidence in social situations” (IDI #11, Male).  Further, many women \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n33\n526 interviewed expressed sentiments of alcohol allowing them to participate in activities “they can’t \n527 do while sober” and “to get rid of shyness” (IDI #3, Female). \n528 Beyond stress and social pressure, some men consumed alcohol because it was both a \n529 tool for connecting with other men and a symbol of social power, IDI #10, Female, for example, \n530 called alcohol use among men “prestigious.” \n531\n532 “Men drink in order to please their friends or the people around them. If the surrounding \n533 people drink he too can drink to feel the sense of oneness with them and to be in one \n534 accord with the rest of the men around him.” (IDI #3, Male)\n535\n536 IDI #15, Female, elaborates on this, saying “there are some girls who prefer to be with a man \n537 who drinks alcohol. As I told you a man who drinks alcohol, he is working and can provide for \n538 the family…he is husband material.” \n539 Alcohol intake helped facilitate social connections for men in part because buying and \n540 consuming expensive alcohol was seen as a metric of financial power –\n541\n542  “Men tend to drink much for showing off to his colleagues and gaining considerable \n543 prestige that he is wealthy” as alcohol could cost “up to three hundred thousand shilling \n544 per day” (IDI #7, Female) (the equivalent of $130 USD).\n545\n546 Importantly, this was not the same for women; while women may have felt social \n547 pressure to drink, respondents remarked specifically that alcohol did not enable social \n548 interactions with other women in the same way that it did for men. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n34\n549\n550 “Men use alcohol as a social catalyst to help people meet and discuss issues…alcohol is \n551 not used among women as a source of them to meet and discuss. Is not as important as it \n552 is for men.” (IDI #4, Male)\n553 When Alcohol Intake Occurs\n554 Overall, respondents reported that the times it was most acceptable to drink were after \n555 their daily tasks were completed, which in some cases differed between men and women. \n556 Because of the longer working hours of women with families, these individuals faced more \n557 restrictions as to when their drinking was seen as appropriate.\n558 In general, respondents noted that men prefer to drink in the “evening times to night \n559 hours after the work hours are over” (IDI #3, Female), but for those who had heavier alcohol use \n560 or are “addicted” (IDI #17, Male) to alcohol,“even in the morning you may find a man is already \n561 drunk” (IDI #13, Female). Drinking in the early hours of the day was linked with being \n562 unemployed in IDIs for men, for example, “for those who do not have permanent work they \n563 drink alcohol from morning they spend all day drinking alcohol” (IDI #6, Female).\n564 In contrast, most respondents agreed that women, especially those with families, faced \n565 more restrictions on when they should drink. This stemmed from their role as the primary family \n566 caretaker, and the reasons underlying this were two-fold: constraints on time, and avoiding \n567 drinking in front of children. Many noted that the full-time responsibility of taking care of the \n568 house and children left women little time to drink – “for women, this is a challenge to get time \n569 free to drink because there are family duties waiting for her to handle” (IDI #3, Female). These \n570 restrictions occasionally were in some instances enforced by male respondents, for example, IDI \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n35\n571 #12, a male, remarked “I told [my wife] that she should drink at the night when there are no \n572 activities at home.” \n573 Beyond the time restraint, women were also perceived as drinking alcohol when it was \n574 less visible by their family and community. Several remarked that mothers should not drink \n575 alcohol in front of their children – “women drink at night when kids are asleep…kids are not \n576 supposed to see the mother drunk, it’s a shame for a mother” (IDI #4, Male) – also because “they \n577 don’t want kids to develop drinking habits” (IDI #2, Male). One went so far as to say – \n578 “[women] are scared to be seen drinking alcohol during the daylight so they use the darkness to \n579 their advantage” (IDI #15, Female). Importantly, even for men who had children, these same \n580 restrictions were not mentioned by any IDI respondent regardless of gender.\n581 These viewpoints on women’s drinking were not held by all, however, one saying that the \n582 time when women drink “don’t differ much with men” (IDI #18, Male) and another noting that \n583 compared to men “time frame are just the same, from evening to night hours after they are done \n584 with work and business” (IDI #16, Female).\n585 Where Alcohol Intake Occurs\n586 Even more than restrictions on appropriate times, strict rules for where a woman could \n587 drink arose among most IDIs. While men could drink anywhere but preferred bars and clubs, \n588 because of the potential for stigma and physical harm surrounding women’s public drinking, \n589 women predominantly drank in the home due to their household duties.\n590 There were few restrictions on where men could drink noted in IDIs – “men are allowed \n591 to drink everywhere” (IDI #12, Male), but the “majority…like to go out to places like pubs, bars, \n592 and nightclubs” (IDI #3, Female). Almost all participants reported that of all places for men to \n593 drink, “most dislike to drink at their homes” (IDI #7, Female), partially to form social \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n36\n594 connections but also as an escape from their home life – “especially in marriages, when there’s \n595 no peace at home it’s easy for a man to drink too much…he spends so much time in bars to avoid \n596 staying at home” (IDI #10, Female). . One participant elaborated on this trend –\n597\n598 “Men prefer to drinking out of their home environment because the main reason is \n599 meetup with friends and discuss business ideas. Just imagine myself I’m always in the \n600 office, and when you go back home you meet a very same person that you always stay \n601 with, hahaha so it’s better to drink in bars or hotel or another place that sells alcohol \n602 where you meet different people and exchange ideas.” (IDI #4, Male).\n603\n604 Women respondents noted that bars and clubs were also desirable for men as a way to avoid \n605 interactions with their wife and meet other women – “if someone has misunderstanding with his \n606 wife, he chooses to go bar and drink with other side women in order to get relief” (IDI #7, \n607 Female).\n608 For women though, the home was mentioned by the vast majority of respondents as the \n609 most appropriate place for women to drink – “women drink at home, it’s very rare to find them in \n610 bars or hotels drinking beers, morally is not allowed unless they go with her husband or \n611 boyfriend” (IDI #4, Male). The remaining few either said that men and women drink in the same \n612 places as men (“[women] now days drinks in the bars and pub because they go with their \n613 husbands. But in other settings women stays at home and drink alcohol” (IDI #11, Male) or that \n614 women should not drink in the home “because kids will be watching you” (IDI #17, Male). \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n37\n615 Respondents also said that women drank at home so that “the community will not \n616 perceive them badly” (IDI #6, Female), alluding to a greater stigma surrounding women’s \n617 alcohol use.\n618\n619 “Finding a woman in a bar drinking alcohol in the early hours of the morning is not quite \n620 appropriate. A man can drink alcohol anywhere but a woman who drinks alcohol where \n621 many people can see her, they will look at her as a drunkard.” (IDI #6, Female)\n622  \n623 Rather, in stark contrast to men, the home was the best location for women’s drinking \n624 because it is a private, “secret” setting where a woman can be with people “she trusts,” (IDI #3, \n625 Female) and likewise, where she can’t be seen: \n626\n627 “Mostly women drink in hiding areas, [they] tend to hide themselves from either the \n628 husband or their relatives, they don’t want others to know if they drink that much. A \n629 woman can leave like she is going to the shop to deceive her relative, while she is \n630 actually going to drink alcohol in the hiding where no one will notice her.” (IDI #7, \n631 Female)\n632\n633 Another underlying factor as to why women did not drink at bars was the risk incurred on \n634 one’s physical safety – “liquor clubs it is not safe for a woman to drink alcohol because when \n635 they drink and get drunk, it often happens violence action against women” (IDI #13, Female). \n636 Echoing this statement, a female college student reported: \n637\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n38\n638 “It is a risk for a woman to go to bars and clubs because of her safety, she may fail to get \n639 back home, get kidnapped, raped and sexually assaulted and lose her belongings… I \n640 have a female friend who drinks so much and that day she went to a club in town and on \n641 her way back she was robbed and beaten, and her belongings were taken. So, it is not a \n642 safe environment for women.” (IDI #3, Female) \n643 What Men and Women Drink and Why\n644 Men and women respondents both agreed that women typically prefer “light alcohols \n645 with smaller percentages of alcohol” whereas men liked “to drink strong liquors alcohol such as \n646 spirits” (IDI #6, Female). These preferences were primarily influenced by alcohol’s ability to \n647 intoxicate the drinker, social clout, and cost. \n648 An overarching theme impacting men and women’s choice of drink was that “men drink \n649 for the aim of becoming drunk” – IDI #12, Male), and since men have a higher alcohol tolerance, \n650 men preferred strong spirits so they could “get drunk faster.” One participant elaborated “Most \n651 men drinks alcohol in Tanzania, whether they drink on public or secretly, but men drinks…Those \n652 who drinks strong beers the main reason is enjoyment and those who drinks local or least costive \n653 beers is because of stress or life hardship!” (IDI #4, Male). In contrast, participants responded \n654 oppositely for women, noting that women “don’t want to get drunk ” (IDI #14, Male), so they \n655 widely gravitated towards lower-percentage and more mild alcohols. These choices for wines \n656 and “light beers” helped women to relax while also allowing them to complete their “daily \n657 activities at home” (IDI #14, Male; IDI #11, Male).\n658 When asked more about why men and women prefer certain beverages, respondents \n659 explained the impact drinks had on interpersonal perceptions and social clout. For men, one \n660 factor contributing to the preference of stronger alcohols was to show their dominance and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n39\n661 importance within the community – “men drink strong alcohol because want to prove to women \n662 that they are superior and above everything (high self-esteem)” (IDI #14, Male). Another echoed \n663 this statement, saying “once he uses strong alcohol...people will view him as a civilized and rich \n664 person instead for those who drinks mbege and other local beers” (IDI #18, Male). These \n665 sentiments on certain alcohol’s social prestige were not mentioned in relation to women.\n666 For men too, echoing the motivations to drink, social clout was heavily tied with wealth \n667 and socioeconomic status. This in turn impacted the type of alcohol they had the ability to buy – \n668 “people with high income drink alcohol of high standards and are expensive but those with low-\n669 income drink local brew” (IDI #14, Male). Men living in more rural areas and of lower \n670 socioeconomic status for example were often marked as drinking the “local brew” that was \n671 widely available, affordable, and lacked testing for alcohol content levels before being sold. One \n672 male participant described:\n673\n674 “Most men drink beer but there are those who drink local brew, so it depends with the \n675 income of that particular person. But sometimes even those who drink beers can fall \n676 under local  brew once they are bankrupt! In the villages the story is different; there \n677 they prefer strong  alcohol, but locally made because it’s cheap and people have no \n678 work to do, you may find them  drinking from morning until late nights.” (IDI #5, Male)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n40\n679 Discussion\n680 This study aimed to explore gender-based differences in alcohol use characteristics \n681 between patients at KCMC's ED and RHC. To the best of our knowledge, this study is the first of \n682 its kind to specifically explore alcohol consumption behaviors stratified by gender, both \n683 quantitatively and qualitatively, in Moshi, Tanzania. While current literature has investigated \n684 alcohol consumption among injury patients in Moshi and has demonstrated gender-specific \n685 differences in alcohol use (4,29) as well as the potential influence of gender stigma on risky \n686 alcohol behaviors (48–51), our study goes one step further to provide an in-depth mixed-methods \n687 analysis on how alcohol consumption and use behaviors differ by gender. Our results indicate \n688 that for men only, alcohol use can facilitate social interactions and act as a boon to their overall \n689 social status. In contrast, women face greater socially sanctioned restrictions surrounding their \n690 drinking and can have less agency than men in their personal alcohol use behaviors. Finally, in \n691 light of these social factors, rates of alcohol use among women patients at KCMC EMD were \n692 significantly higher than at the RHC, with male patients likewise exhibiting especially high use \n693 compared to the surrounding Moshi community. For populations in this region experiencing \n694 alcohol-related harm, understanding key sociocultural gender differences in alcohol use can more \n695 appropriately inform, target, and tailor future alcohol-related interventions.\n696 We found that for men, alcohol was viewed both as a tool for connecting with other men \n697 and as a symbolic representation of their social power. This connotation encouraged men to \n698 drink, to do so in social settings like bars, and to consume expensive liquors as a marker of their \n699 economic status. Two recent studies in Moshi and one in neighboring Uganda (52) have \n700 similarly described alcohol as a form of “social currency” and “an important part of social \n701 celebrations” (53), however, without delineating whether this association is skewed by gender. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n41\n702 This lack of delineation may stem from the aim of these studies which focus on overall drinking \n703 culture as opposed to gender differences in drinking. Even still, a finding in Osaki’s work that \n704 young men feel greater pressure to initiate alcohol intake from their peers than young women \n705 (53) parallels ours. This disproportionate peer pressure on men likely stems from alcohol use is \n706 more interlinked to men’s social lives than women’s.\n707 While specific data on male drinking and social power in the African context is lacking, \n708 this association may find its roots in traditional African cultural practices, where alcohol has \n709 been traditionally reserved for high-class men (54). Among the Nyakyusa people of Southern \n710 Tanzania (55), for example, men who were older and more socially respected were the primary \n711 consumers of beer. The reliance on alcohol as a social tool and symbol among men in Moshi \n712 likely contributes to higher continued rates of alcohol use. Concerningly, the fact that alcohol is \n713 interwoven into the fabric of male social life may likely make it even more difficult for male \n714 problematic drinkers to reduce or abstain from intake in this region.\n715 In stark contrast to alcohol’s interconnectedness with male social life, we found that \n716 women experience significant social restrictions around drinking and tend to have less agency \n717 than men in their personal alcohol use behaviors. Previous studies in Tanzania and neighboring \n718 regions have found social influences (12,13) affect alcohol use, but there is a significant dearth \n719 of data on how women’s alcohol use is impacted by sociocultural-based gender roles and \n720 responsibilities. Our findings did have strong parallels to what relevant research was available, \n721 specifically two studies based in Tanzania. Work by Griffin et al found that women who drink \n722 experience disproportionate social stigma (49) and literature by Meier et al found that drinking \n723 publicly is considered culturally inappropriate for women but not so for men. In addition to \n724 social stigma and sanctions, this finding by Meier et al is likely a result of the potential physical \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n42\n725 harm women stand the risk of incurring while drinking in public spaces as the link between \n726 alcohol use and gender-based violence has been well-established (56,57). Interestingly, our \n727 finding stood opposite to Dumbili et al’s work in Nigeria where young women consumed \n728 excessive quantities of alcohol to gain social capital (12). This may be because, while on the \n729 same continent, Nigeria and Tanzania have distinct cultural differences that social capital is \n730 achieved in different manners. \n731 An important consequence of the heightened restrictions around women’s drinking is that \n732 it leads to secretive alcohol use behaviors, a finding that has a unique clinical implication for \n733 women’s healthcare. As we found in this analysis, some women did not want others to see them \n734 consuming alcohol which led them to drink at night, in private locations, or only around certain \n735 people. This alludes to a wider stigma around women’s alcohol use, which is concerning as \n736 stigma has been associated globally (51,58–60) and within Africa (61) as a barrier to effective \n737 healthcare service delivery. Because women who drink in Tanzania have been shown to face \n738 greater stigma than men, this obstacle in alcohol use-related treatment delivery may be especially \n739 prominent for them (49). Thus, women’s secretive alcohol consumption, a behavior born out of \n740 stigma and social restrictions around their drinking, will likely make it difficult for healthcare \n741 workers to identify, diagnose, and treat women with unhealthy alcohol use. \n742 In addition to the sociocultural and economic factors that serve as determinants for \n743 alcohol consumption, we found that the highest incidence of alcohol misuse was present within \n744 the ED at KCMC. While potentially harmful alcohol consumption was the most pronounced \n745 among male ED patients specifically (38%), female ED patients also exhibited higher rates of \n746 concerning alcohol use compared to their RHC counterparts (17% ED and 7.4% RHC). \n747 Comparing our findings with local estimates, Mitsunga and Larsen found that 7% of women with \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n43\n748 partners, 9.3% of women without partners, and 22.8% of men tested positive for alcohol abuse \n749 (alcohol abuse here defined as a CAGE score of 2-4) (4). Mushi et al. observed the prevalence of \n750 AUDIT ≥ 8 (HHD) to be 23.9% for outpatient primary healthcare patients in Moshi, and when \n751 stratifying for gender, 38.7% of males and 13.1% of females tested positive for HHD (29) \n752 compared to our findings of HHD among 38% of ED men patients and 17% of ED women. Rates \n753 of HHD were comparable among men in these two studies, but for women, a significant \n754 difference could be seen. This suggests that KCMC’s ED has a particularly high concentration of \n755 women with high-risk alcohol use compared to other populations in Moshi.\n756 Our finding of higher rates of alcohol use among men versus women echoes current \n757 global trends (13,62,63). The global literature also supports the increased rates of alcohol use and \n758 high-risk drinking behaviors present within EDs compared to other hospital departments or \n759 wards. This is because of alcohol’s close association with trauma and injuries potentially \n760 requiring more immediate medical care (32,64). For those with limited access to care because of \n761 financial constraints, EDs may serve as one of the only options to obtain health services for \n762 minor alcohol-related consequences. Within the east Africa and LMIC context, previous research \n763 has also found elevated rates of alcohol use among ED patients in Tanzania, most often \n764 presenting with injuries resulting from road traffic incidents (65). The high rates of harmful \n765 alcohol consumption among both men and women ED patients in Tanzania suggest that the ED \n766 may be an optimal site for alcohol-related interventions. \n767 While alcohol-related harm was not central to this analysis, it is important to emphasize \n768 not only the negative impact excessive alcohol use can cause on the Moshi community but also \n769 the opportunities for reducing this burden moving forwards. The findings discussed in this \n770 manuscript – the high proportion of unhealthy alcohol users in KCMC’s ED, the restrictions \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n44\n771 imposed on women’s alcohol use and resulting secretive drinking behaviors, and the association \n772 between social life and alcohol use for men – all provide valuable insight that can be used to help \n773 shape future alcohol-reduction interventions more effectively. \n774 First, our finding that the ED had a significantly high proportion of unhealthy alcohol \n775 users, especially women users, suggests that this clinical unit may be a good location in which to \n776 base alcohol-related interventions. This is especially important when considering our finding of \n777 women’s limited agency and secretive behaviors around their alcohol use. The lack of agency \n778 women have around drinking may impede the delivery of alcohol-related treatments. However, \n779 an ED-based intervention could help to efficiently target this high-risk group and do so as part of \n780 their usual care. Thus, an ED-targeted intervention may provide additional benefits to high-risk \n781 women within the community who may face greater social restrictions in accessing alcohol-\n782 related health services. Second, the significant dissimilarities in men’s and women’s alcohol use \n783 behaviors – from where, when, what, and why they drink – point to the need for creating alcohol-\n784 related interventions that are differentiated by gender. For example, as shown in our analysis, the \n785 reasons for drinking varied by gender – for men, they were more closely tied to social pressure \n786 and lack of opportunity whereas for women it was mostly related to relationship stress. In \n787 reducing alcohol intake, the underlying causes of drinking must be addressed, but as this \n788 comparison shows, different sociocultural and environmental factors are important for men \n789 versus women in their alcohol use. Alcohol-reduction-related interventions and programs that are \n790 conscientious of gender differences in alcohol use behaviors may be more able to bring about a \n791 lasting change in consumption patterns.\n792 Several limitations were present in this study. Despite extensive measures at ensuring \n793 confidentiality, patient recall of alcohol use characteristics may have been implicated by recall \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n45\n794 bias, whereby subjects could not accurately recount drinking behaviors, or subjects were cautious \n795 of exposing their drinking habits to investigators. Moreover, women were more likely to decline \n796 study participation, with primary reasons being (a) they did not wish to discuss their alcohol use,  \n797 and (b) concern for privacy. Consequently, it is important to consider the possibility that our \n798 study did not capture the full extent of alcohol consumption among women given the \n799 implications of gender stigma present in this context. That is, it may be that women are more \n800 reluctant to share the extensiveness of their drinking behaviors in fear of being stigmatized by \n801 community, and family members. This may have influenced the accuracy and validity of these \n802 results. Additionally, survey and IDI data was obtained from three different clinical settings, \n803 warranting replication and external validation. Although missing data was not significant, we \n804 must also be weary of the external validity of our results. Subsequently, further studies should be \n805 conducted, and replicated at additional clinics, with limited missing data and increased assurance \n806 of confidentiality and comfortability.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n46\n807 Conclusion\n808 Men and women patients at KCMC’s ED and RHC were found to have significant \n809 differences in their alcohol use behaviors, including lower rates of consumption among women, \n810 greater social restrictions around women’s drinking, and more secretive alcohol use behaviors \n811 including where and when women could drink. Conversely, for men, excess drinking was \n812 normalized within the Moshi community, tied to men’s social interactions with other men, and \n813 generally motivated by stress, social pressure, and despair over lack of opportunity. These \n814 dissimilarities point to the need for future alcohol-related programs to incorporate gender in their \n815 design and implementation. 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The \n988 prevalence of alcohol and illicit drug use among injured patients presenting to the emergency \n989 department of a national hospital in Tanzania: a prospective cohort study. BMC Emerg Med. 2019 \n990 Jan 24;19(1):15.\n991\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n52\n992 Supporting Information\n993 1. S1 – IRB Approval – Duke University\n994 2. S2 – IRB Approval – KCMC\n995 3. S3 – IRB Approval – NIMR \n996 4. S4 – STROBE Checklist\n997 5. S5 – PLOS Checklist\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 18, 2023. ; https://doi.org/10.1101/2023.05.12.23289897doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}