Dissertation

Submitted to

THE TAMILNADU Dr. M.G.R MEDICAL

UNIVERSITY

In partial fulfilment of the requirements for

the award of the degree of

M.D COMMUNITY MEDICINE

Branch XV

May 2019

“PREVALENCE AND SOCIAL FACTORS ASSOCIATED

WITH ALCOHOL USE AMONG MEN IN THIRUVATTAR”

CERTIFICATE

This is to certify that this dissertation entitled “Prevalence And Social Factors

Associated With Alcohol Use Among Men In Thiruvattar” is a bonafide record

of the work done by Dr.M.S.Praythiesh Bruce during the period 2016-2019. This

has been submitted in the partial fulfilment of the award of M.D. Degree in

Community Medicine [Branch-XV] by the Tamilnadu Dr. MGR Medical

University Chennai.

Dr.M.C Vasantha Mallika.M.D.,DPH.

Professor and Head

Department of Community Medicine

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

Dr.Rema.V.Nair.M.D., D.G.O.

Director

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

CERTIFICATE

This is to certify that this dissertation entitled “Prevalence And Social

Factors Associated With Alcohol Use Among Men In Thiruvattar”hereby

submitted by Dr. M.S.Praythiesh Bruce for the M.D. Degree in Community

Medicine [Branch-XV] in the Tamilnadu Dr. MGR Medical University is a

record of bonafide research work carried out by him under our guidance and

supervision during the period 2016-2019.

Dr.Austoria A.J.M.D.

[Co-guide]

Assistant Professor

Department of Community Medicine

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

Dr.M.C Vasantha Mallika.M.D.,DPH.

Professor and Head

Department of Community Medicine

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

DECLARATION

I Dr. M.S.Praythiesh Bruce hereby submit the dissertation titled

“PREVALENCE AND SOCIAL FACTORS ASSOCIATED WITH

ALCOHOL USE AMONG MEN IN THIRUVATTAR” done in partial

fulfilment for the award of the degree M.D Community medicine

[Branch-XV] in Sree Mookambika Institute of Medical Sciences,

Kulasekharam.

This is an original work done by me under the guidance and supervision

of Dr. M.C.Vasantha Mallika M.D., DPH. and Dr. Austoria A.J.M.D.

Dr.M.S.Praythiesh Bruce

Postgraduate

Department of Community

medicine

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

Dr. M.C. Vasantha Mallika.M.D., DPH.

Professor and Head

Department of Community Medicine

Sree Mookambika Institute of

Medical Sciences

Kulasekharam

Kanyakumari District

Tamil Nadu -629161

ACKNOWLEDGEMENT

My foremost thanks goes to the God Almighty who has blessed me abundantly with

His grace, for giving me the strength that I needed to complete this thesis.

I extend my sincere heartfelt thanks to Dr. Velayuthan Nair, Chairman and Dr.

Rema. V. Nair, Director, for providing facilities to accomplish my dissertation work. I also

thank the Principal of the Institution Dr. Padmakumar and vice principal Dr.Mookambika

R.V and Deputy Medical Superindent Dr. Vinu Gopinath for their valuable support

extended to me.

I express my sincere thanks and gratitude to my professor, mentor and guide Dr.M.C

Vasantha Mallika, Head of the Department, for her valuable and constant guidance,

supervision and support throughout the study. Her constant motivation has helped me to

overcome all the challenges and difficulties that I came across during this research work.

I am very much grateful to my co-guide Dr. Austoria .A.J., Assistant Professor, for

her tremendous help, valuable support and guidance in carrying out the study. Her constant

encouragement helped me to overcome obstacles during the study.

I wish to express my sincere thanks to Dr.Sudhir Ben Nelson Assistant Professor,

for his help and valuble suggestions during the study period

I wish to express my sincere thanks to Dr.Vishnu.G.Ashok Assistant Professor, for

his help and valuble suggestions during the study period.

I also thank Dr.Priya, Assistant Professor, for the help during the study period.

I humbly thank Ms.Jossy John, Lecturer in Statistics, Department of Community

Medicine, for the support, guidance and help at each stage of my dissertation work.

I also thank my Junior Post Graduates for their help and support.

I am very grateful for the support, encouragement and care given by parents and

friends whenever I needed most.

Mrs. Ambika Kumari deserves special mention for her help and cooperation.

DEDICATED TO MY PARENTS, BROTHER,

SISTER, TEACHERS, FRIENDS,

COLLEGUES & MY DEAR WIFE

Without whom I would have never reached to this

stage of life.

CONTENTS

SL.NO TITLE PAGE NO.

1 INTRODUCTION 1

2 AIMS & OBJECTIVES 4

3 REVIEW OF LITERATURE 5

4 MATERIALS & METHODS 33

5 RESULTS 40

6 DISCUSSION 76

7 SUMMARY & CONCLUSION 90

8 LIMITATIONS 91

9 RECOMMENDATIONS 92

10 REFERENCES -

11 ANNEXURES -

LIST OF TABLES

Prevalence of alcohol use among Men in states and union territories in India 11

Table 1: Distribution of study population based on age 41

Table 2: Distribution of study population based on religion 42

Table 3: Distribution of study population based on marital status 42

Table 4: Distribution of study population based on educational qualification 43

Table 5: Distribution of study population based on occupation 44

Table 6: Distribution of study population based on income 44

Table 7: Distribution of study population based on Modified Kuppuswamy socio

economic classification 45

Table 8: Alcohol use among the study population 46

Table 9: Distribution of ever alcohol users 46

Table 10: Alcohol use disorder according to AUDIT category 47

Table 11: Dependence category for current alcoholics 48

Tables 12: Frequency of alcohol use among ever and current alcohol users 49

Table 13: AUDIT score among current alcohol users (n = 232) 50

Table14: Age of initiation of alcohol and awareness about it. 50

Tables 15: Place of alcohol use among ever and current alcohol users 51

Tables 16: Company for alcohol use among ever and current alcohol users 52

Tables 17: Type of alcohol use among ever and current alcohol users 53

Table 18: Reason for Starting Alcohol among Ever and Current Alcohol user 54

Table19: Reason for continuing alcohol use in ever and current alcohol user. 55

Table 20: Efforts to stop alcohol use among ever and current alcohol users 56

Table 21: Factors Associated with alcohol use among ever and never alcohol users 58

Table 22: Factors Associated with alcohol use among ever and never alcohol

users-Odds (95%CI)

61

Table 23: Factors associated with alcohol use among current alcohol users 64

Table 24: Factors associated with alcohol use among current alcohol users-

Odds(95%CI)

67

Table 25: Factors associated with alcohol dependence among current 70

Table 26: Factors associated with alcohol dependence among current users-

Odds(95%CI)

74

LIST OF FIGURES

Figure 1 Total alcohol per capita(15+ years) consumption; in liters

of pure alcohol, 2010

7

Figure 2 Proportion (%) of recorded alcohol per capita (15+)

years consumption consumed in the form of beer, wine,

spirit and other beverages by WHO region and world

29

Figure 3 Flow chart depicting the prevalence of alcohol use

among men in Thiruvattar block aged 18 and above

40

1. INTRODUCTION

Alcoholic beverages have been consumed from the beginning of the

recorded history of human society1. Both the developed and underdeveloped

countries have been suffering from the abuse of alcohol2. As per World Health

Organization[WHO] Global status report 76.3 million are diagnosed with alcohol

use disorders in 2 billion people consuming alcohol3. Due to harmful use of

alcohol 5.9 % of all deaths that occur worldwide. Globally, 3.3 million deaths

occur every year. Alcohol is a causal factor in more than 200 disease and injury

conditions. Overall 5.1 % of the global burden of disease and injury are due to

Alcoholism, as measured in disability-adjusted life years (DALYs). Death and

disability occur early in life and it is mainly seen in 20-39 years and 25 % of the

total deaths among this age group are attributable to alcohol. There is a causal

relationship between the harmful use of alcohol and a range of mental and

behavioural disorders and other non-communicable diseases and injuries. Harmful

use of alcohol brings significant social and economic losses to individuals and

society4. Some countries in the South-East Asia Region are moving to a higher

level of alcohol use in the last decade.

The globalization of the economies in the South-East Asia Region (SEAR)

is increasing and so it leads to increase alcohol consumption which leads to

abuse/harmful use and also addiction (dependence) . The alcohol industry is

expanding hugely in the Region. In the period between 1993-94 the total annual

estimated alcohol production was 642 million litres and it has doubled to 789

million litres in 2 years during 1994-1995 5 . In 2006 – 2007 in Tamilnadu 13.6%

of the total state revenue was generated through the sale of alcohol. Tamil Nadu

Government took over the retail sales of alcohol in a policy change in 2003. Illicit

alcohol trade was wiped out through a series of measures. The Tamil Nadu State

Marketing Corporation (TASMAC) was the sale outlets, apart from a few high-

end bars and hotels. An increase of 40.34% in turnover was noted and an

additional revenue of Rs. 15.64 billion was generated in the first 11 months when

retail alcohol sales were taken over by the Government6

The revenue earned through a special fee on imported foreign liquor sales

was increased in TASMAC from 1.86 crores [2010-2011] to 10.80 crores in

[2016-17 ]6.The export of beer from Tamilnadu to other states has been increased

from 1,15,00[2015-16] to 1,27,150 cases [2017-18]7.

The prevalence of alcohol use among men in India as per National Family

Health Survey[NFHS]-4 [2015-16] was 29.2%8.The highest prevalence was seen

in Arunachal Pradesh (59%) and lowest prevalence was seen in New Delhi ( 0.7%

) as per NFHS-4 [2015-16]. The prevalence of alcohol use in Tamilnadu as per

NFHS-4 was 46.7% [2015-16]8. The magnitude and pattern of alcohol behavior,

alcohol exposure (volume, patterns, and quality of alcohol consumed), economic

development, culture, and existing alcohol-related policies are determined by a

number of factors associated with individual and social levels like

poverty,illiteracy3

The rapid proliferation of city bars and nightclubs lead to increase in sale

of alcohol to 8 % in the past three years in India due to which about 14 million

people are dependent drinkers. The average age of initiation of alcohol use has

dropped down from 19 years to 13 years in the past two decades9. The spectrum of

alcohol use ranges from one- time use, regular use, hazardous use and harmful use

The quantity of alcohol consumed in each individual also have varying strength as

per alcohol consumption occur in different quantity, frequency, type of beverage

and alcohol concentration across type of beverage. In developing country alcohol

consumption is on the rise adding to the burden of the alcohol-attributable disease.

WHO formulated a tool called [Alcohol Use Disorder Identification Test] AUDIT

tool which is used widely across the world in primary care levels to quantify

alcohol use and disorder associated with it. The AUDIT is the simple method of

screening for excessive drinking and to assist in brief assessment. AUDIT helps to

identify excess drinking and provide a framework of intervention to help

hazardous and harmful drinkers reduce or cease alcohol consumption and avoid

the harmful consequences of their drinking10,11.

Various surveys had been done to find the each individual’s drinking

pattern .An individual’s drinking pattern can be related to other personal

characteristics and behaviour12--15.

Hence knowing the prevalence and social factors associated with alcohol

use, it will be helpful to suggest control measures. So this study was conducted to

estimate the prevalence and social factors associated with alcohol use among adult

men in Thiruvattar block of Kanyakumari District, Tamil Nadu in South India.

2. OBJECTIVES

1. To estimate the prevalence of alcohol use among adult men in Thiruvattar block.

2. To identify the patterns of alcohol use by using the AUDIT scoring system

3. To find the social factors associated with alcohol use

3. REVIEW OF LITERATURE

3.1 HISTORY:

Alcohol is the oldest and the most widely used drug according to the old

Arabic dictionaries. Al- Kol (Al- ghol) means any drug or substance that takes

away the mind or covers it. Moderate amounts of alcohol stimulate the mind and

relax the muscles.

The Greeks had employed wine and vinegar in wound care. Alcohol-

containing beverages played a vital part in the daily lives of ancient people. Beer is

the fermented form of barley, the earliest known alcoholic drink to man10.In 1790

The East India Company for the first time imposed excise duty on alcohol as a

regular source of revenue. 19th century, the policy of the Government of India was

to minimize temptation among those who did not drink, and discourage excess use

among those who were drinking ’. After independence, the prohibition movement

survived till the mid-1960s, when several states lifted the prohibition. The

prohibition orders were soon reversed as states lost nearly 20-25% of alcohol-

related Revenue16-19.

Although the Constitution of India upholds prohibition in its directive

principles, the liberalization in the production, distribution, and consumption of

alcohol is well known in most states. Since the trade liberalization in 1992–93, the

attitudes of the Central and State governments to alcohol have changed

dramatically with the previous restrictions on consumption and production being

relaxed. Alcohol multinationals eagerly took advantage of India's economic

liberalization and relaxation of regulations in order to invest in local beverage

production for the country's market. Improved fermentation and distillation

process and packing technology resulted in alcoholic beverages belonging to a

mass-produced commercial item. Improved intra country transport facility

contributed to its easy availability16-19

3.2 CURRENT PATTERNS OF ALCOHOL USE:

3.2.1 WORLD SCENARIO:

According to WHO data, globally, individuals above 15 years of age drink

on an average 6.2 litres of pure alcohol per year ( Figure 1 ). There is a wide

variation in total alcohol consumption across WHO regions and Member States (

Figure 1). The highest consumption levels continue to be found in the developed

world, especially in the WHO European Region (EUR) and the WHO Region of

the Americas (AMR). Intermediate levels of consumption are found in the WHO

Western Pacific Region (WPR) and the WHO African Region (AFR) The lowest

consumption levels are found in the WHO Eastern Mediterranean Region(EMR)

(Figure 2).

( Figure 1 )3 shows Total alcohol per capita(15+ years) consumption; in liters of

pure alcohol, 2010

Geographical differences exist regarding the type of alcohol people consume [

beer, wine, spirits or other alcoholic beverages (e.g. fortified wines, rice wine or

other fermented beverages made of sorghum, millet or maize)].Globally, 50.1% of

total recorded alcohol is consumed in the form of spirits, the most consumed

beverage types in the WHO South-East Asia and Western Pacific regions (Figure

2). The second most consumed beverage types is beer, which accounts for 34.8%

of all recorded alcohol consumed in the world. It is the most consumed type of

beverage in the WHO Region of the Americas (55.3%). 8.0% of total recorded

alcohol is consumed in the form of wine. The consumption of wine represents one-

fourth of total consumption in the WHO European Region (25.7%) and one-ninth

of total consumption the WHO Region of the Americas (11.7%) "Other" beverages

only represent 7.1% of all consumption, but constitute the most popular beverage

type in the African Region (51.6% of total recorded consumption)3.

3.3 INDIAN SCENARIO:

India has seen a rapid proliferation of city bars and nightclubs in recent

years. It has led to undocumented rise in alcohol abuse not only among the poorer

classes, but also in sections of society that were previously considered dry. The

increasing production, distribution, and promotion of alcohol has led to drink-

related problems emerging as a major public health concern in India. Sales of

alcohol have seen a growth rate of 8% in the past 3 years. 21% of adult men and

around 2% of women drink. But up to a fifth of this group are dependent

drinker20-23.

3.3.1 PREVALENCE OF ALCOHOL USE

1.1 INDIA:

As per NFHS -4 (2015-2016) prevalence of alcohol use among Men in India

is 29.2%8.

Prevalence of alcohol use among Men in various states and union territories

in India is listed below in the table8.

States /union territories Prevalence of alcohol among men (%)

HIMACHAL PRADESH 39.7%

HARYANA 24.5%

DAMAN &DIO 35.8%

ARUNACHAL PRADESH 59.0%

TAMILNADU 46.7%

WEST BENGAL 28.7%

UTTARKAND 35.2%

UTTAR PRADESH 22.1%

TRIPURA 57.6%

TELUNGANA 53.9%

SIKKIM 51.2%

RAJASTHAN 15.9%

PUDHUCHERRY 41.0%

PUNJAB 34%

NAGALAND 39%

MIZORAM 49.6%

MADHYAPRADESH 29.6%

MANIPUR 52.6%

MEGHALAYA 44.0%

MAHARASHTRA 20.5%

LAKSHADWEEP 6.8%

KERALA 37%

KARNATAKA 29.3%

JAMMU &KASHMIR 10.5%

JHARKHAND 39.3%

GUJARAT 11.1%

GOA 44.7%

DADRA &NAGAR HAVELI 33.9%

NCT DELHI 0.7%

CHATTISGARH 52.7%

CHANDIGARH 39.3%

BIHAR 28.9%

ASSAM 37.8%

ANDRA PRADESH 34.9%

3.3.1.2 PREVALENCE IN TAMILNADU:

As per NFHS -4 (2015-2016) prevalence of alcohol use among Men in

Tamilnadu is 46.7%8.

3.4.1 PATTERNS OF DRINKING IN INDIA20-23:

There has been a rapid change in patterns and trends of alcohol use in India.

The most important among them is the initiation of drinking at an younger age.

The percentage of the drinking population aged under 21 years has increased from

2% to more than 14% in the past 15 years. The “average age of initiation” had

dropped from 19 years to 13 years in the past two decades. The local industry has

introduced flavoured alcohol drinks to attract previously non-drinking women and

young men. Multinational companies have identified India as one of the world’s

most sought after places for investment. Two thirds of the alcohol drunk in India is

unrecorded because it is either illicit liquor or has been smuggled into the country.

Employers in poor, marginalised communities sometimes pay wages in alcohol

rather than cash, according to WHO. The hazards of spurious liquor can be fatal,

with frequent reports of death, disability, and hospitalisation resulting from its

consumption across the country20-23.

3.4.2A.AGE OF INITIATION OF ALCOHOL USE :

The average age of initiation had dropped from 19 years to 13 years in the

past two decades in India20-23.

3.5. SPECTRUM OF ALCOHOL USE:

In different societies and in the proportions of population in different

groups the drinking spectrum of alcohol varies considerably11.

3.5.1 HARMFUL USE:

Harmful use refers to alcohol consumption that results in consequences to

physical and mental health and social consequences among the harms caused by

alcohol11

Harmful alcohol use pattern causes serious damage to health. That can be

physical (prolonged use of alcohol can cause hepatitis) or mental (e.g. heavy

alcohol consumption can lead to episode of depressive disorder)11.

Ganesh Kumar et al in a rural community based cross-sectional study

revealed that the prevalence of alcohol use was found to be 9.4%. Prevalence was

more among males (16.8%) as compared to that among females Among those who

used alcohol, 29.2% (26) were possible hazardous drinkers, 33.7%(30) had a

probable alcohol dependence and 56.2% (50) had experienced harmful effects,

based on AUDIT item analysis24-27.

In a community-based cross-sectional analytical study done by

Purushothaman Vaithiyanathan et al (April 2016 to March 2017) among adult

residents of the coastal villages of Puduchery, south India reported that the

prevalence of alcohol use was 152 (61.5%, 95% CI- 55.4%-67.5%), 63 (25.5%,

95% CI- 20.4%-31.2%) had harmful use of alcohol and 20 (8.1%, 95% CI- 5.2%-

12.0%) had probable dependence to alcohol. The study showed very high

prevalence of alcohol use and harmful use of alcohol in coastal villages. Stringent

regulatory approaches and effective health education approaches were much

needed for the control of alcohol use and harmful use of alcohol28-31.

A community-based, cross-sectional study by Santanu Ghosh et al during

(May 2008–April 2009) at a Slum in Kolkata, India revealed that 65.8% (150/228)

were current consumers of alcohol; 14% were alcohol-dependents; 8% were

hazardous or harmful to consumers, and 78% were nonhazardous non-harmful

consumers32-35.

3.5.2. HAZARDOUS ALCOHOL USE:

Hazardous alcohol use is a pattern of alcohol consumption that increases

the risk of harmful consequences for the user or others 11.

A cross sectional study from Goa by Melvin Chagas Silva et al found that

the prevalence of hazardous drinking, defined as per AUDIT score of more than 8

was 21%. There was a significant association with Common Mental Disorders (OR

2, P = 0.003). Hazardous drinking was significantly associated with severe health

problems, such as head injuries and hospitalization, whereas Common Mental

Disorders was found to be a confounder in its association with adverse economic

outcomes36-39.

A Case-control study conducted by John et al in Kaniyambadi block,

Vellore district, Tamil Nadu among adult men found that the in the past year

prevalence of lifetime use was 46.7% and alcohol hazardous use was 14.2%. The

risk factors for hazardous use of alcohol were using Indian made foreign liquor

(OR 20.51; 95% CI 8.81–47.75) and living in a village which brewed illicit alcohol

(OR 2.82; 95% CI 1.39–5.72)40-43.

3.5.3. DEPENDENCE SYNDROME:

This includes a cluster of physiological, behavioural, and cognitive

phenomena in which the use of a substance or a class of substances takes on a

much higher priority than other behaviours that once had greater value for a given

individual. A character of the dependence syndrome is the desire (often strong,

sometimes overpowering) to take the psychoactive drugs (which may or not have

been medically prescribed), alcohol, or tobacco44-47..

Rakshase Bal et al in a cross-sectional, descriptive study done at

Thiruvananthapuram reported that Alcohol Dependence among males in

Thiruvananthapuram was as high as 38.41%. Alcohol Dependence was associated

with socio-demographic factors such as marital disharmony, poor income, poor

education, and unemployment. Alcohol use was influenced by religious factors. By

addressing the issue of social deprivation at a macro level alcohol Dependence can

be curbed48-51.

A hospital-based cross-sectional descriptive study by Santhosh Kumar et al

in Psychiatry Out Patient Department of a tertiary care Medical institute at Bareilly

in Uttar pradesh done among 50 male patients of alcohol dependence syndrome

show that in comparison to normal controls, the patients of alcohol dependence

syndrome had significantly higher mean scores on the Scale for Suicide Ideation

(t=2.858, df=98, p<0.01), Beck Depression Inventory-Short Form (t=3.082, df=98,

p<0.01) and the State subscale (t=3.465, df=98, p<0.01) as well as the Trait

subscale (t=3.508, df=98, p<0.01) of State Trait Anxiety Inventory. So the male

patients of the alcohol dependence syndrome had significantly higher suicidal

ideation ,depression ,and state and trait anxiety scores as compared to normal

controls52-55.

A study conducted by Surjit Kumar Sen et al at Silchar Medical College

and Hospital, Silchar, in December 2015 to February 2016 found that the

Majority of alcohol dependence cases were from the age range of 35 to 44 years

(44%) while their primary caregivers from 30 to 39 years (44%). Most of the cases

had their spouses (74%) as the primary caregivers and 10–14 years of alcohol

dependence (34%). The higher family burden was associated with equal to or more

than 15 years of alcohol dependence which was statistically significant in most of

the areas The severity of family burden was greatly influenced by the duration of

the alcohol dependence of the cases52-55.

A cross-sectional study undertaken in the various wards of Jabalpur

Cantonment in India by Rajendra Harnagle et al in an urban community of

Jabalpur found that among 3586, 434 (12.10%) were found to have a Alcohol

dependence syndrome (ADS) i.e. 7.96 % of the total strength was found to be

problem drinkers. Persons improved at the end of 12 months were 280 out of 434

by Alcoholic Anonymous counseling. 64.51%. were available for the complete

follow-up study . The ADS had significantly reduced by Alcoholic Anonymous

counseling at six months itself (p<0.000). This improvement not only sustained at

12 months, but further improved upon (p<0.004). So the improvement was highly

significant (p<0.000). The prevalence of alcohol dependence syndrome was

increasing globally. In India the ADS had been significantly reduced by alcoholic

anonymous counseling.56.

3.5.4. RECENT CHANGES IN ALCOHOL CONSUMPTION

PATTERNS:

There has been a rapid change in alcohol consumption patterns in India.

Important among them is people are beginning to drink at ever-younger ages. The

minimum legal age for starting alcohol consumption in India was 21 years. The

percentage of the drinking population aged under 21 years has increased from 2%

to more than 14% in the past 15 years9,57-60.

3.6. EFFECTS OF ALCOHOL:

Alcohol has many uses in human life. These include beverage use (fuel,

solvent) and non beverage use and also used as medicine, religious sacrament

,food stuff and thirst quencher. Alcohol acts as a depressant. It can also affect

mood and feelings, impairs physical coordination, cognition, attention, resulting in

accidents and injury. Prolonged alcohol use can cause death and disability1,61-64.

Nidhi Goel et al in a multicentre cross-sectional study among medical

undergraduates and postgraduate medical residents of eight medical colleges

across India reported that substance use adversely affected their skills in 90% of

study participants.25-27 .

Bhullar et al in a study done among second-year medical students found

that almost all cases showed degeneration in the form of delirium tremens,

Korsakoff’s psychosis or acute hallucinosis. The study also found that 25% of the

cases had suffered from road accidents while under the effect of alcohol. Only a

minority of the cases (3%) were members of Alcoholic Anonymous or other such

Organizations involved in encouraging people to give up alcohol.57.

3.6.1. HEALTH CONSEQUENCES OF ALCOHOL USE:

As per World Health Organization [WHO] Global status report 76.3

million are diagnosed with alcohol use disorders among 2 billion people who are

consuming alcohol. Due to harmful use of alcohol 5.9 % of all deaths occur

worldwide and 3.3 million deaths occur every year. Alcohol is a causal factor in

more than 200 disease and injury conditions. Overall 5.1 % of the global burden of

disease and injury are due to Alcoholism, as measured in disability-adjusted life

years (DALYs). Death and disability come early in life and it is mainly seen in 20-

39 years and 25 % of the total deaths among this group are attributable to alcohol.

There is a causal relationship between the harmful use of alcohol and a range of

mental and behavioral disorders and other non-communicable disease and injuries.

The latest reports show relationships between harmful drinking and diseases like

tuberculosis and HIV/AIDS. Harmful use of alcohol brings significant social and

economic losses to individuals and society3,65,66.

3.6.2 SOCIAL PROBLEMS ASSOCIATED WITH ALCOHOL USE:

Alcohol consumption can cause many problems for the individual, his

immediate environment and society. The social consequences are workplace-

related problems, family and domestic problems, and interpersonal violence. The

effects of alcohol aggravate the causes of poverty by increasing malnutrition,

absenteeism at work, road traffic accidents and loss of productivity. Social

consequences due to alcohol can affect individuals other than the drinker e.g.

passengers involved in traffic casualties, or family members affected by failure to

fulfill social role obligations, or incidences of violence in the family67

Vijay Ramanan et al in a rural cross sectional study done at Thirubuvanai

and Nettapakkam PHC areas in pudhucherry reported that the overall prevalence

of alcohol use among ≥18 years of age was 9.7% and exclusively among males

was 17.1%. The highest prevalence (17.1%) was among 46–55 year age groups

and the residents of joint families (37.0%). One third of the users began drinking

before 20 years of age and half of them consumed in getting relief from

pain/strain/tiredness. About half of the users had strained relations with their

family members and neighbours both. The majority had alcohol dependence

problems and about one fifth had chronic health problems such as diabetes

mellitus, and hypertension. The prevalence of alcohol use was high among males

and low among uneducated farmers67.

3.6.3. ALCOHOL AND FAMILY:

A Cross-Sectional Study done by Gayathri Vijaya Lakshmi et al at a

Tertiary Care Setting among 100 patients and their spouses showed that Co-

morbid psychiatric disorders were found in sixty-two percent of the participants.

68% had medical co-morbidities. Spouses who were physically abused (67%) also

experienced other forms of abuse at similar rates viz., Emotional abuse (63%),

Economic abuse (52%), and Sexual abuse (65%). Among women reporting

domestic violence, 11% had attempted suicide. The majority of those reporting

domestic violence exceeded cut-off scores for a depressive disorder. The severity

of violence correlated positively with the Brief Psychiatric Rating Scale

(psychopathology) scores. These findings highlight the importance of screening

alcohol dependent patients for psychopathology, spouse for domestic violence and

its complications in mental health settings58.

Shridevi Kotina et al in a community-based cross-sectional study among

244 persons revealed that Prevalence of substance abuse to be 66%. 48.54% were

consuming alcohol and 23.36% were smoking. Skilled workers (67%) were

addicted. 87.66% of illiterates were addicted. 52% of subjects started alcohol use

due to peer pressure and 41% started only as experimenting 62.

A cross-sectional study by Avi Singh et al among medical college students

in September 2016-October 2016 reported that 61.29% males and 8.24% females

showed both tobacco use and alcohol abuse. In the case of alcohol consumption,

80.65% males and 35.29% of females consumed some form of alcohol. Overall

43% of respondents abused alcohol and tobacco to relieve stress. The alcohol and

tobacco are major substances being abused by young medical graduates in spite of

universal knowledge that they are source of major non communicable diseases63.

3.6.4. ALCOHOL CONSUMPTION AND WORKPLACE:

Persons who consume alcohol have higher rates of sickness absence than

other employees. Alcohol consumption can lead to decrease productivity in

industries. Heavy alcohol drinking can lead to unemployment, but loss of work can

also result in increased drinking, which may lead to heavy alcohol drinking68.

A cross-sectional study conducted by Subhash Chakraborty et al in the

psychiatric department of an urban industrial hospital in Southern India among

urban industrial employees found that out of 43 subjects, absenteeism was present

in 18 while those who did not have absenteeism was 25. Comparing the two

groups, interstate migration, having more than one previous job, commuting time

more than an hour, co‑morbid anxiety/depression, and alcohol abuse was

significantly associated with absenteeism (P < 0.05).68 .

Giridhara Ret al in a cross-sectional online study done among software

professionals revealed that the Subjects who were professionally stressed had 5.9

times higher prevalence of harmful alcohol use compared to those who were not

professionally stressed. Subjects who were at risk for developing depression had

4.1 times higher prevalence of harmful alcohol use compared with those who were

not at risk for developing depression69.

3.6.5. ALCOHOL CONSUMPTION AND FAMILY:

The functioning capacity is impaired by alcohol among its consumers.

Alcohol consumption affects the drinker’s partner as well as the children. Alcohol

consumption during pregnancy in women can lead to fetal alcohol syndrome.

Parental drinking can lead to child abuse and affects the child’s social,

psychological and economic environment. Drinking costs money and can impact

upon resources of a poor family. Diversion of money for alcohol use that could

have otherwise been used for seeking medical care, may lead to delay in seeking

health care70.

Surjit, Kumar Sen et al in a cross-sectional single interview case study

done at the Silchar Medical College and Hospital Assam revealed that majority of

alcohol dependence cases were from the age range of 35 to 44 years (44%) while

their primary caregivers from 30 to 39 years (44%). Most of the cases had their

spouses (74%) as the primary caregivers and had 10–14 years of alcohol

dependence (34%). Majority of the primary caregivers suffered from a moderate

type of family burden, especially in areas such as disruption of routine family

activity, recreation, and family interaction. The higher family burden was

associated with equal to or more than 15 years of alcohol dependence which was

statistically significant in most of the areas. The severity of family burden was

greatly influenced by the duration of the substance dependence of the cases70.

A cross-sectional study by Alok Tyagi et al done among 30 subjects who

were wives of alcohol-dependent men admitted to the de-addiction ward of a

hospital in Jaipur, India found out that the majority of the sample were housewives

(66.7%), of the Hindu religion (83.3%), had received at least primary education

and were living in a nuclear family (53.3%). Mean duration of alcohol

consumption by the husbands was 9.60 years (SD 2.79). Among the alcohol users,

the mean AUDIT score was 11.47 ± 4.05. The mean Patient Health Questionnaire-

9 score among the wives was 4.87 ± 5.49. The correlation between variables

measuring alcohol intake and PHQ-9 and MSSI scores showed that depressive

symptomatology in the wife was significantly and positively correlated with the

AUDIT scores. There was a strong correlation between AUDIT scores and suicidal

ideation in wives measured by the Modified Scale for Suicidal Ideation. Those

with suicidal ideation stated that concerns about their children's upbringing and

their future were the main reasons which prevented them from killing themselves.

There was a significant positive correlation between alcohol consumption in

husbands and depressive symptoms and suicidal ideation in their wife71.

3.6.6. ALCOHOL USE AND ECONOMIC CONSEQUENCES:

The expenditures related to alcohol are high in poor marginalised areas.

Money is spent on alcohol, and also drinker suffers other expenditures. The direct

cost includes medical cost and lost earnings due to death and disability. The

indirect costs include loss of work, loss of school, meeting the burden, loss of

savings, extra loans made, assets sold, work replacement/support, cost of the

employer/society and low self-esteem. In road traffic accidents due to alcohol the

accidental injuries, vehicle and property damages are huge72.

A Population survey by Aravind Pillai et al done in rural and urban

communities in northern Goa, India reported that 732 male drinkers were

screened from 1,899 men, aged 18 to 49 years who were randomly selected. Lower

education and a Lower standard of living (Standard Living Index) were associated

with a higher usual quantity of alcohol consumption.72.

3.6.7. ALCOHOL AND DOMESTIC VIOLENCE:

The behavior of the alcoholics may cause physical, psychological or sexual

harm to those in their relationship. It includes acts of physical aggression

(slapping, hitting, kicking or beating), psychological abuse (intimidation, constant

belittling or humiliation), forced sexual intercourse or any other controlling

behaviour (isolating a person from family and friends, monitoring their movements

and restricting access to information or assistance73.

A Cross-sectional study by Dixit Sanjay et al done at Domestic Violence

counselling centre in the Psychiatry Department of Maharaja Yeshwantrao

Hospital OPD reported that the common type of domestic violence faced was

physical (80%) followed by mental (8%), social (8%) and sexual (4%). Monetary

issues (26%) and alcoholism (22%) were the two most important causes of

domestic violence. Other causes were extramarital affair (6%), family conflicts

(6%) and dowry (6%). 64% victims were either illiterate or primary pass; 34%

were skilled workers; 56% victims had their per capita income between 980 and

2935; 76% had their modified Kuppuswami score between 5-10. 56 % victims face

domestic violence daily. The monetary problems, alcoholism, illiteracy,

extramarital affairs, and dowry were the causes of domestic violence73.

A population-based cross-sectional study was carried out by Ajay k.

Jawarkar et al done from 1 May 2015 to 31 July 2015 in the field practice area of

the Rural Health Training Centre of Dr. Panjabrao Deshmukh Memorial Medical

College, Nerpinglai in Amravati district of Maharashtra state. Out of 400 study

participants interviewed, 161 (40.25%) reported some type of violence i.e. either in

the form of physical, emotional or sexual violence in their lifetime or in the recent

past. The most common type of violence reported was physical violence. The most

common cause of domestic violence reported in their study was financial problems

followed by influence under alcohol58-60.

3.6.8. ALCOHOL AND POVERTY:

Shekhar saxena et al reports that the poor people take refuge in alcohol to

alleviate the unendurable suffering of their lives. In some circles drinking was

explained as the natural and expected response to misery. Alcohol was popularly

assumed to be a way of temporarily escaping for a short while the harsh realities

were associated with poverty. Quite apart from whether alcohol itself alleviates

suffering, the simple formulation that the poor drank because it helped them

alleviate their suffering 74.

A study done by Shekhar saxena et al between May and July 1997 in a

poor urban community (‘slum’) located in the southern part of Delhi, North India,

shows that family with at least one adult consuming alcoholic drink at least three

times every week in the previous one month. They spent 14 times more on alcohol

per month and had financial debt significantly higher than family with no adult

consuming alcoholic drinks more than once in the previous one month. Family

with at least one adult consuming alcoholic drinks at least three times every week

in the previous one month reported significantly more cases of major illnesses.

They perceived significantly less severe health, social and economic effects of

drinking than those from family with no adult consuming alcoholic drinks more

than once in the previous one month74.

3.7. ALCOHOL USE DISORDERS IDENTIFICATION TEST

The World Health Organisation developed the AUDIT questionnaire which

was used for screening for excessive drinking and to assist in brief assessment

AUDIT helps to identify excessive drinking and also provide framework for

intervention to help hazardous and harmful drinkers reduce or cease alcohol

consumption and thereby avoid the harmful consequences of their drinking.

The AUDIT will help the practitioner to identify whether the person has

Hazardous (or risky) drinking, Harmful drinking, or Alcohol dependence.

The test has the following domains: (i) Harmful use of alcohol (items:

frequency of drinking, quantity, frequency of heavy drinking), (ii) Dependence

symptoms (items: impaired control over drinking, increased salience of drinking,

morning drinking), (iii) Harmful alcohol use (items: guilt after drinking, blackouts,

alcohol-related injuries, others concerned about drinking). It is a simple method for

screening and classifying consumers of alcohol.

AUDIT scores >8 suggest harmful and hazardous drinking and require advice on

reduction; scores >16 suggest severe alcohol problems and demand brief

counseling while those >20 mandate detailed assessment and treatment for alcohol

dependence. The questionnaire is brief and flexible11.

3.7.1 SCORING AND INTERPRETATION OF AUDIT:

AUDIT questionnaire by WHO was used for collecting data on the

prevalence of alcohol use and alcohol use disorder. Audit questionnaire has 10

questions, first 3 on consumption quantity and frequency, next 3 to assess drinking

behaviour and dependence and last 4 on consequences and problems related to

drinking.

The first 8 questions are scored 0,1,2,3 or 4 and the last two questions are

scored 0, 2 or 4. Total score on AUDIT is 40. People who obtain scores of 0-7 are

considered to have low risk of alcohol use. People obtaining 8-15 come under

hazardous alcohol use, 16 – 19 under harmful alcohol use and scores of 20 and

above are termed high risk alcohol use.

The combined score for questions 4, 5, and 6 is termed the dependence

score. If the dependence score is 4 or more, or if the total AUDIT score is 16 or

more (with any dependence score), the individual should be assessed for

dependence. Individuals with a dependence score of 3 or less with a total AUDIT

score of 15 or less are considered not dependent. 11.

3.7.2. STUDY ON VALIDITY OF AUDIT SCORE:

A large community-based cross-sectional study conducted in Goa by Paige

endsley et al among adults aged 18-49 years and residing in the study area between

2006 and 2008 found that AUDIT showed high internal reliability and acceptable

criteria on validity with adequate psychometric properties for the detection of

alcohol abuse and dependence75.

A study by Pal HR et al done among 297 consecutive subjects who had

used alcohol in the previous year recruited from a de-addiction center shows that

the AUDIT alcohol use disorders identification test had very high internal

reliability (alpha 0.92) in this Indian sample. . The AUDIT alcohol use disorders

identification (area under the curve [AUC] = 0.883) and SMAST Short Michigan

Alcoholism Screening Test (AUC = 0.870) were similar in detecting harmful use

of alcohol76.

3.8. ALCOHOL RELATED POLICIES75 :

To reduce the public health burden of alcohol consumption the policy

options are available which are divided into three main groups namely

,Population-based policies, Problem-directed policies, and Direct interventions

I. Population-based policies

These policies are aimed at altering levels of alcohol consumption among the

population. They include

1) Policies on taxation,

2) Advertising,

3) Availability,

4) Controls including prohibition,

5) Rationing and state monopolies,

6) Promotion of beverages with low or no alcohol content,

7) Regulation of density of outlets, hours and days of sale,

8) Drinking locations and minimum age of initiation of drinking, health

promotion campaigns, and school-based education.

One of the most effective ways to prevent alcohol-attributable disease is by

reducing the overall availability of alcohol, which can generally impact the

average amount of alcohol consumed.

There is evidence that taxation and pricing policies can disproportionately

impact lower-income drinkers by making alcohol less affordable for them and

reducing their consumption.

II. Policies is aimed at specific alcohol-related problems

This group of policies are directed to problems,

1. Such as drunken driving (e.g. promoting widespread random breath testing)

2. Alcohol-related offenses

III Policies involves interventions directed at individual drinkers

1. These include brief interventions,

2. Treatment and rehabilitation programmes.

Except for the brief interventions, many such ‘treatments’ are administered

only to those individuals with the most severe problems75.

3.8.1 ALCOHOLICS ANONYMOUS (AA)77:

Alcoholics Anonymous is an nonprofessional, self-supporting,

nondenominational, apolitical organisation. There are no age or educational

requirements for joining in it. It was started in 1935 by a New York stock broker,

Bill Wilson and an Ohio surgeon Dr. Bob Smith, who had drinking problems.

They founded this organization in an effort to help others who suffered from the

disease of alcoholism and to stay sober themselves. This organization grew with

the formation of autonomous groups, first in the United States and then around the

world. In India it was started in Mumbai in 195777.

Alcoholics Anonymous: Twelve Step program of spiritual and character

development.

The relative success of this programme seems to be due to the fact that an

alcoholic who no longer drinks has an exceptional faculty for “reaching” and

helping an uncontrolled drinker.In simplest form, this programme operates when a

recovered alcoholic passes along the story of his or her own problem drinking,

describes the sobriety he or she has found in Alcoholic Anonymous and invites the

newcomer to join the informal Fellowship.

1. We admitted we were powerless over alcohol that our lives had become

unmanageable

2. Came to believe that a Power greater than ourselves could restore us to

sanity.

3. Made a decision to turn our will and our lives over to the care of God as we

understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature

of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make

amends to them all.

9. Made direct amends to such people wherever possible, except when to do

so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly

admitted it.

11. Sought through prayer and meditation to improve our conscious contact

with God as we understood Him, praying only for knowledge of His will for

us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to

carry this message to alcoholics and to practice these principles in all our

affairs

Newcomers are not asked to accept or follow these Twelve Steps if they

feel unwilling or unable to do so.New comers will usually be asked to keep an

open mind and also advised to attend meetings at which recovered alcoholics

describe their personal experiences in achieving sobriety, and advised to read the

literature describing and interpreting the Alcoholic Anonymous programme77.

3.9. POLICY NEED IN INDIA78:

As per Indian Constitution ‘The State shall endeavor to bring about prohibition

of the consumption of intoxicating drinks.’ Growing awareness of the problem of

alcohol consumption in India has been reflected in many policy initiatives. Except

for a few states, which have promulgated prohibition there is increasing

liberalization in alcohol production and availability. Prohibition was undertaken in

some states, but it has failed to reduce alcohol-related problems and gave rise to

some additional problems. In India alcohol prohibition is a state subject with each

state having full control of alcohol legislation, state excise rates and production

and sale of alcohol.

Prohibition policies are of 3 main types:

1. Complete prohibition of production and consumption;

2. Partial prohibition where one or more types of liquor (usually arrack) is

prohibited

3. In certain days of the week or month dry days is followed in which the

consumption is prohibited

Most states enforce a few ‘days’ in the year as ‘dry’ (no alcohol sales) and

restrict the time for sale on other days78.

4. MATERIALS AND METHODS

4.1 STUDY DESIGN:

Community based Cross Sectional Study.

4.2 STUDY SETTING:

Thiruvattar block of Kanyakumari district, Tamilnadu state, South India.

4.3 STUDY PERIOD:

March 2017 to July 2018(1 ½ year).

4.4 STUDY SUBJECTS:

Men aged more than 18 years residing in Thiruvattar block area for more

than last 6 months.

4.5 INCLUSION CRITERIA:

Men aged more than 18 years who were residents of Thiruvattar block for

more than last 6 months.

4.6 EXCLUSION CRITERIA:

a. Mentally challenged.

b. Seriously ill /bed ridden patients.

c. Men who were not present in the residence during data collection.

d. Men satisfying the inclusion criteria, but not giving informed

consent.

4.7 SAMPLE SIZE :

The prevalence of alcohol use among men in Tamil Nadu as per NFHS-4

report was 46.7%6

Sample size was calculated using the formula Sample size (n) =Zα2pq/d2

Where,

Zα = 1.96

P = 46.7%

q=100-p=100-46.7=53.3

d is the relative precision = (10 % of p ), i.e. 4.67

n=1.962pq/d2

= 438

Giving a 10 % non response rate, Sample size was 482.

4.8 SAMPLING TECHNIQUE:

Two stage Sampling Technique was used.

Stage 1:

Thiruvattar block consist of 16 panchayats namely Ayacode, Aruvikkara,

Cherukole, Surulode, Kannaoor, Kumarankudy, Yettacode, Pechipparai,

Kattathurai, Balamore, Attoor, Kulasekharam, Ponmanai, Thiruvattar, Thripparapu

and Verkizhambi. In each panchayat there are about 15 wards. One ward from

each panchayat was selected randomly by lottery method.

Stage 2:

The list of house from the panchayat was used as the sampling frame from

the selected ward, 32 houses were chosen by computer generated random number

method. From the selected house one adult male was selected for the study. If there

was more than one man in the house,one of them was chosen by lottery method.

If no man was present in the house, the next house was chosen by random number

technique and was visited till the sample size was obtained.

4.9 STUDY VARIABLES:

Age

Education level

Occupation

Relation with the head of the family

Socio- economic variables

Alcohol use in the family

Availability of alcohol

Alcohol in use in daily life

Alcohol use by the participant

Factors influencing alcohol use

AUDIT score

4.10. STUDY TOOLS:

The following instruments were used:

Pretested Questionnaire

AUDIT questionnaire

AUDIT questionnaire by WHO was used for collecting data on the prevalence

of alcohol use and alcohol use disorder. Audit questionnaire has 10 questions, first

3 on consumption quantity and frequency, next 3 to assess drinking behaviour and

dependence and last 4 on consequences and problems related to drinking.

The first 8 questions are scored 0,1,2,3 or 4 and the last two questions are

scored 0, 2 or 4. Total score on AUDIT is 40. People who obtain scores of 0-7 are

considered to have low risk of alcohol use. People obtaining 8-15 come under

hazardous alcohol use, 16 – 19 under harmful alcohol use and scores of 20 and

above are termed high risk alcohol use.

The combined score for questions 4, 5, and 6 is termed the dependence

score. If the dependence score is 4 or more, or if the total AUDIT score is 16 or

more (with any dependence score), the individual should be assessed for

dependence. Individuals with a dependence score of 3 or less with a total AUDIT

score of 15 or less are considered not dependent. 11. AUDIT scores >8 suggest

harmful and hazardous drinking and require advice on reduction; scores >16

suggest severe alcohol problems and demand brief counseling while those >20

mandate detailed assessment and treatment for alcohol dependence. The

questionnaire is brief and flexible11

(i) Harmful use of alcohol (items: frequency of drinking, quantity,

frequency of heavy drinking), (ii) Dependence symptoms (items: impaired control

over drinking, increased salience of drinking, morning drinking), (iii) Harmful

alcohol use (items: guilt after drinking, blackouts, alcohol-related injuries, others

concerned about drinking). It is used as a simple method for screening and

classifying consumers of alcohol.

The audit original questionnaire was in English version and it was

translated in Tamil, and Malayalam

Short pilot study was done among 40 people

4.11 OPERATIONAL DEFINITIONS:

1) Standard drink (SD) = 1 can beer (330 ml at 5%) = 1 glass wine (140 ml at

12%) = 1 shot spirit (40 ml at 40%) = 12.6 grams of pure alcohol

2) Abstainers: adult men who reported never drinking in their life,

3) Ex-drinkers: adult men who had not consumed alcohol in the previous 12

months.

4) Drinkers: adult men who reported drinking alcohol at least once during the

previous 12 months.

5) Binge drinking: Binge drinking is defined as the consumption of 5 or more

standard alcoholic drinks on one occasion

6) Current alcohol users- Men who continued to consume the alcohol during

the last one year of study.

7) Ever alcohol users- Men who were consuming alcohol.

8) Never alcohol users- Men who never consumed alcohol in their life time.

9) Harmful use: A pattern of alcohol consumption that causes damage to

health. The damage may be physical (as in cases of hepatitis from

prolonged use of alcohol) or mental (e.g. episodes of depressive disorder

secondary to heavy consumption of alcohol).

10) Hazardous use: Hazardous use is a pattern of alcohol consumption carrying

with it a risk of harmful consequences to the drinker.

11) The damage may be to health–physical, or mental, or they may include

social consequences to the drinker or others. This is therefore called alcohol

abuse

12) Alcohol abuse, also called “problem drinking”, is a pattern of excessive

drinking that result in adverse health and social consequences to the drinker,

and often to those around the drinker9

4.12 PROCEDURE IN DETAIL:

The study commenced after obtaining permission from Institutional

Research Committee and Institutional Human Ethical Committee, The study was

conducted among 464 adult men who were residing in Thiruvattar block for

more than last 6 months and the subjects qualifying the inclusion and exclusion

criteria were interviewed with a pre tested semi structured questionnaire by the

principal investigator after getting informed consent. The responses were filled up

by the investigator. Any translation or explanation required was done by the

investigator Privacy was ensured before conducting the interview. Data on socio-

cultural practices, family history, utilization of alcohol in daily life, age of starting,

frequency, and type of alcohol consumption were collected. WHO AUDIT

questionnaire was filled along with it to screen for excessive drinking among

alcohol users and to classify the consumers of alcohol.

Data collection was done using the pretested semi-structured interview

schedule and information on variables such as age, income, education, marital

status and type of family, family history, age at first drink, use of alcohol in the

past year and preferred type of alcohol were recorded.

4.13 DATA ENTRY AND STATISTICAL ANALYSIS:

Software used for data entry: Study parameters were entered in Microsoft

Office Excel 2013

Software used for statistical analysis: IBM SPSS trial Version 20.0

All quantitative variables were expressed in terms of mean with standard

deviation and median with inter quartile range. All qualitative variables were

expressed as proportions Factors associated with alcohol use and alcohol use

disorder were determined by bivariate analyses using chisquare test for qualitative

variables. Multi variable analyses were done using binary logistic regression for

determining the independent risk factor of alcohol use and alcohol use disorder.

5. RESULTS

A cross-sectional study was done to find the prevalence of alcohol use

among men aged 18 and above in the Thiruvattar block , Kanyakumari District,

Tamilnadu from March 2017 to July 2018., using AUDIT questionnaire. Required

sample size was calculated to be 482, About 482 individuals were eligible out of

which 464 responded making the response rate of 96.46% for the present study.

Non response rate was 3.54%.

Figure 3: Flow chart depicting the prevalence of alcohol use among men in Thiruvattar

block aged 18 and above

TOTAL NUMBER OF PARTICIPANTS-

464

EVER ALCOHOL USERS-258

CURRENT ALCOHOL USERS-

232

LOW RISK ALCOHOL USE-101

ALCOHOL USE DISORDERS-131

HAZARDOUS ALCOHOL USE-70

HARMFUL/SEVERE ALCOHOL USE-27 HIGH RISK USE-34

CURRENT NON ALCOHOL USERS -

26

NEVER ALCOHOL USERS-206

5.1.BASELINE CHARACTERISTICS:

5.1.1AGE:

The median age of the 464 study participants were 32.50 with an

interquartile range of 71 and the mean age was 37.63 with a standard deviation of

17.121.The minimum age is 18 years and maximum age 89 years. The age of the

study participants was classified into 5 categories. Out of the 464 study

participants 196 (42.2%) belong to the age category of 18-29 years, 129 (27.8%) of

them belong to 30-44 years, 71 (15.3%) participants belong to 45-59 years, 68

(14.7%) are above 60 years of age [Table 1].

Table 1: Distribution of study population based on age

Age category ( in years of age ) Number (%)

18 – 29 196(42.2%)

30- 44 129(27.8%)

45 – 59 71(15.3%)

60 and above 68(14.7%)

Total 464(100%)

Among the participants 196(42.2%) are in age group 18-29 followed by

129(27.8%).

5.1.2 RELIGION :

Out of 464 study participants, 168 (36.2%) belonged to Christian religion

and 151 (32.5%) were of Hindu religion and 145 (31.3%) were of Muslim religion

[Table 2].

Table 2: Distribution of study population based on religion

Religion Number (%)

Hindu 151(32.5%)

Christian 168(36.2%)

Muslim 145(31.3%)

Total 464(100%)

Among the participants 168(36.2%) are Christians followed by Hindus

151(32.5%).

5.1.3 MARITAL STATUS:

Out of 464 study participants, 320(69%) were married and 89 (18.2%) were

divorced and 55 (11.9%) were unmarried. [Table 3]

Table 3: Distribution of study population based on marital status

Marital status Number (%)

Married 320(68.96%)

Unmarried 55(11.85%)

Divorced 89(19.19%)

Total 464(100%)

Most of the participants 320(68.96%) were married followed by unmarried

89(19.18%).

5.1.4 EDUCATIONAL QUALIFICATION:

Among 464 study participants, 78 (16.8%) completed graduate or post

graduate, 78 (16.8%) completed post high school (11th-12th), 135(29.1%)

completed high school education (8th - 10th), 60 (12.9%) completed middle school

(5th -7th), 56(12.1%) completed primary (up to 4th) and 57 (12.3%) were illiterate.

[Table 4]

Table 4: Distribution of study population based on educational qualification

Education Number (%)

Illiterate 57 (12.3%)

primary school Certificate 56(12.1%)

Middle school certificate 60 (12.9%)

High school certificate 135(29.1%)

Post high school certificate 78 (16.8%)

Graduate or postgraduate 78(16.8%)

Total 464(100%)

Among the participants 135(29.1%) are high school certificate followed by

78 (16.8%) post high school certificate and graduate or post graduate.

5.1.5 OCCUPATION:

Among 464 study participants 108 (23.3%) of them are unemployed and

70(15.1%) of them are un skilled and 108(23.3%) of them are skilled and 43(9.3%)

of them are clerical and 22(4.7%) of them are semi-profession and 30(6.5%) of

them are profession. [Table 5]

Table 5: Distribution of study population based on occupation

Occupation Number (%)

Unemployed 108 (23.3%)

Unskilled 70(15.1%)

Semiskilled 83(17.8%)

Skilled 108(23.3%)

Clerical 43(9.3%)

Semi-profession 22(4.7%)

Profession 30(6.5%)

Total 464(100%)

5.1.6 INCOME:

Among 464 study participants 24(5.1%) Less than 2009 rupees, and

89(19.18%) 2010-5968 rupees and 59(12.71%) 5969-9947 rupees, and 77(16.59%)

9948-14,921 rupees, and 156(33.62)14922-19895 rupees and 45(9.69%) 19896-

39,790 rupees and 14(3.0%) 39,791 rupees and above [Table 6]

Table 6: Distribution of study population based on income

Income Number (%)

Less than 2009 rupees 24(5.12%)

2010-5968 rupees 89(19.18%)

5969-9947 rupees 59(12.71%)

9948-14921 rupees 77(16.59%)

14922-19895 rupees 156(33.62%)

19896-39,790 rupees 45(9.69%)

39791 rupees and above 14(3.09%)

Total 464(100%)

Among the participants 156(33.62%) are having a income of 14922-19895

followed by 89(19.18%) having a income of 2010-5968 rupees.

5.1.7 SOCIOECONOMIC STATUS:

As per modified kuppuswamy classification 13(2.8%) belong to lower

class(less than 5), 179(38.5%) belong to upper lower class(5-10), 181(39.0%)

belong to lower middle class(11-15), 87(18.7%) belong to upper middle class(16-

25), 4(0.8%) belong to upper class(26-29) [Table 7]

Table 7: Distribution of study population based on modified kuppuswamy

socio economic classification

Modified Kuppuswamy

Socioeconomic status classification

Number (%)

Lower Class(less than 5) 13(2.8%)

Upper Lower Class(5-10) 179(38.7%)

Lower Middle Class(11-15) 181(39.0%)

Upper Middle Class(16-25) 87(18.7%)

Upper Class(26-29) 4(0.8%)

Total 464(100%)

The majority of the participants 181(39.0%) belong to lower middle class followed

by 179(38.5%) belong to upper lower class.

5.2 PREVALENCE OF ALCOHOL USE:

5.2.1 PREVALENCE OF ALCOHOL USE AMONG THE STUDY

POPULATION:

Of the 464 study participants, 258(55.6%) were ever alcohol users and 206

(44.44%) were never users that they had never used alcohol in their life time.

[Table 8]

Table 8: Alcohol use among the study population

Alcohol Use Frequency(N=464) Percentage (%)

Ever alcohol user (n=258) 55.6%

Never user (n=206) 44.4%

5.2.2 EVER ALCOHOL USE

Of the 464 study participants the ever alcohol users were 258(55.6%)

among the ever alcohol users 232(50%) were current alcohol users that is those

who continue to consume alcohol and 26 were those who were previously

consuming alcohol but had stopped consuming it for more than one year in the

study period[Table 9].

Table 9: Distribution of ever alcohol users

Alcohol Use Frequency(N=258) Percentage (%)

Current alcohol user (n=232) 89.93%

Current non alcohol user (n=26) 10.07%

Out of 258 ever users the current alcohol users is 232(89.92%) and current

non alcohol users is 26(10.07%).

5.2.3 ALCOHOL USE DISORDER

The AUDIT scores was introduced for the 232 current alcohol users .The

mean audit score for 232 current alcohol users was 11.59 with a standard deviation

of 8.502. Median Audit score was 9 with an interquartile range of 35.

These 232 current alcohol users were categorized into low risk alcohol use and

those with alcohol use disorder according to AUDIT scores.

Out of the 232 current alcohol users, 101 (44%) of them were having low

risk alcohol use and 131(56%) had alcohol use disorder.

Out of the total of 464 subjects, proportion of those with alcohol use

disorder was found to be 28.23%. [Table 10]

Table 10: Alcohol use disorder according to AUDIT category

SL

NO

Alcohol use disorder Frequency (%)

1 Hazardous Drinking 70(53.5)

2 Harmful/Severe Drinking 27(20.6)

3 High Risk /Alcohol dependent 34(25.9)

4 Total (Alcohol use disorder ) 131(100)

The most of them 70(53.43) belongs to hazardous drinking followed by

34(25.95) belongs to high risk/alcohol dependent.

5.2.4 ALCOHOL DEPENDENCE

The combined AUDIT score for questions 4,5,6 is termed the dependence

score if the dependence score is 4 or more or if the total AUDIT score is 16 or

more (with any dependence score ) the individual should be assessed for

dependence. Individuals with a dependence score of 3 or less with a total AUDIT

score of 15 or less are considered non independent. Current alcoholics (N=232)

were assessed for dependence using AUDIT score. It was found that 160 (68.9%)

out of 232 were not dependent and 72(31.03%) needed to be assessed for

dependence. When the dependence scores were analyzed, it was found that 11

(4.74%) out of 232 had dependent score higher than 4 and 61 (26.29%) out of 232

had dependent score less than 4 with an audit score of 16 or higher. Hence these 72

participants need to be assessed for dependence. [Table 11]

Considering the total 232 subjects, prevalence of those who should be assessed for

dependence was 31.03%. [Table 11]

Table 11: Dependence category for current alcoholics

SL

NO

Dependence category Frequency (%)

1 Not dependent 160(68.96)

2 Should assess for dependence 72(31.04)

3 Total 232(100%)

The majority was 160(68.96%) non dependent followed by 72(31.03%) those who

should be assessed for dependence.

Tables 12: Frequency of alcohol use among ever and current alcohol users

Ever alcohol users Current alcohol users

Pattern Of Alcohol Use Frequency

Percent

(%)

Frequency Percent (%)

Monthly or less 54 20.9 54 23.3

2 to 4 times a Month 65 25.2 65 28

2 to 4 times a Week 55 21.3 47 20.3

4 or more times aWeek 84 32.6 66 28.4

Total 258 100 232 100

Among 258 ever alcohol users the frequency of alcohol use among most of

them was 84(32.6%) are using alcohol four or more times a week followed by

65(25.2%) are using alcohol two to four times a month.

Among 232 current alcohol users the frequency of alcohol use among most of

them was 66(28.4%) are using alcohol four or more times a week followed by

65(28%) are using alcohol two to four times a month.

5.3 AUDIT SCORE

The table 19 shows pattern among current alcohol users. Thirty four

individuals in this group are in need of special alcohol de-addiction care (14.7 %)

Table 13: AUDIT score among current alcohol users (n = 232)

AUDIT score zones Frequency Percentage

1-7(with in harmless zone) 101 43.5

8-15(hazardous drinking) 70 30.2

16-19(Severe alcohol problem) 27 11.6

20-40(alcohol dependent) 34 14.7

Total 232 100

The most of them 101(43.5 %) belongs to low risk zone (1-7) AUDIT score

followed by 70(30.2%) belongs to hazardous drinking AUDIT score (8-15).

5.4 INDIVIDUAL PATTERN OF ALCOHOL USE AMONG THE STUDY

GROUP:

5.4.1 AGE OF INITIATION OF ALCOHOL AND AWARENESS ABOUT

IT:

Table14: Age of initiation of alcohol and awareness about it.

Variable

Ever alcoholic(n=183)

mean age in years

Never alcoholic(n=132)

mean age in years

Age at First awareness

about alcohol

12.63±2.53 15.30±2.02

Age at First use of

alcohol

24.32±2.99 22.66±1.781

5.4.2 PLACE OF ALCOHOL USE AMONG EVER AND CURRENT

ALCOHOL USERS:

Tables 15: Place of alcohol use among ever and current alcohol users

Ever alcohol users Current alcohol users

Place of alcohol

consumption

Frequency (%) Frequency (%)

Home 57(22.13) 57(24.6)

Restaurant 19(7.36) 19(8.2)

Friends room 71(27.51) 71(30.6)

Hide Out 55(21.31) 55(23.7)

Social Gathering 26(10.07) 26(11.2)

Hostel & Other 30(11.62) 4(1.7)

Total 258(100) 232(100)

Among 258 ever alcohol users the most of them 71(27.51%) are using

friends room as the place of alcohol use followed by 57(22.09%) are using home

as their place of alcohol consumption.

Among 258 ever alcohol users the most of them 71(30.6%) are using

friends room as the place of alcohol use followed by 57(24.6%) are using home as

their place of alcohol consumption.

5.4.3 COMPANY FOR ALCOHOL USE AMONG EVER AND CURRENT

ALCOHOL USERS:

Tables 16: Company for alcohol use among ever and current alcohol users

Company for alcohol use Ever alcohol users Current alcohol users.

Frequency (%) Frequency (%)

Alone 41(15.90) 40(17.2)

Friends 87(33.72) 87(37.5)

Family Members 40(15.50) 20(8.6)

Others/specify-family

relatives

90(34.88) 85(36.7)

Total 258(100) 232(100)

Among 258 ever alcohol users, the most of them 90 (34.88%) are having

company as family relatives followed by friends 87(33.72%) are having company

of alcohol consumption.

Among 232 current alcohol users, the most of them 87 (37.5%) are having

company as family relatives followed by friends 85(36.5%) are having company of

alcohol.

5.4.4 TYPE AND FREQUENCY OF ALCOHOL USE AMONG EVER AND

CURRENT ALCOHOL USERS TABLE (23 & 24):

Tables 17: Type of alcohol use among ever and current alcohol users

Type of Alcohol use Ever alcohol users Current alcohol

users

Brand Frequency (%) Frequency (%)

1.Whisky 51(19.76) 51(22)

2. Rum 42(16.27) 42(18.1)

3.Beer 32(12.44) 32(13.8)

4.Toddy 25(9.68) 25(10.8)

5.Brandy 42(16.27) 42(18.1)

6.All Type 29(11.24) 29(12.5)

7.Others (More Than one

Brand)

37(14.34) 11(4.7)

Total 258(100) 232(100)

Among 258 ever alcohol users the most of them 51(19.76%) are using

whisky as the type of alcohol use followed by 42(16.27%) are using rum and

brandy brand as the type of alcohol consumption.

Among 232 ever alcohol users the most of them 51(22%) are using whisky as

the type of alcohol use followed by 42(18.1%) are using rum and brandy brand as

the type of alcohol consumption.

5.4.5 REASON FOR STARTING AND CONTINUING ALCOHOL AMONG

EVER AND CURRENT ALCOHOL USERS (TABLE 18) (TABLE

19):

Table 18: Reason for Starting Alcohol among Ever and Current Alcohol user

Reason For Starting Alcohol Use Ever alcohol

users

Current alcohol users

Frequency(%) Frequency(%)

Peer pressure 69(26.7) 51(22.0)

Curiosity 64(24.8) 53(22.8)

Curiosity and peer pressure 48(18.6) 32(13.8)

To feel with the crowd 24(9.3) 25(10.8)

To work more 24(9.3) 42(18.1)

Others 29(11.3) 29(12.5)

Total 258(100) (100)

Among 258 ever alcohol users the reason for starting alcohol use among

most of them was peer pressure 69(26.7%) followed by 64(24.8%) curiosity.

Among 258 ever alcohol users the reason for starting alcohol use among

most of them was Curiosity 53(22.8%) followed by 51(22.0%) peer pressure.

Table19: Reason for continuing alcohol use in ever and current alcohol user.

Reason for continuing

alcohol use

Ever alcohol users Current alcohol users

Frequency (%) Frequency (%)

Peer pressure 59(22.8) 59(25.4)

Like the effects 55(21.3) 55(23.7)

Can work more 36(14.0) 36(15.5)

Withdrawal symptoms 33(12.8) 33(14.2)

Maintain social status 19(7.4) 19(8.2)

To get good sleep 25(9.7) 25(10.8)

To forget problems 17(6.6) 5(2.2)

Others 14(5.4) 0(0)

Total 258(100) 232(100)

Among 258 ever alcohol users the reason for continuing of alcohol use

among majority of them was peer pressure 59(22.9%) followed by 55(21.3%) like

the effects of alcohol.

Among 232 current alcohol users the reason for continuing of alcohol use

among majority of them was peer pressure 59(25.4%) followed by 55(23.7%) like

the effects of alcohol.

5.4.6 EFFORTS TO STOP ALCOHOL USE AMONG EVER AND

CURRENT ALCOHOL USERS (TABLE 20):

Table 20: Efforts to stop alcohol use among ever and current alcohol users

Ever alcohol user

(N=258)

Current alcohol user (N=232)

Tried to stop

alcohol use

Frequency Percentage Frequency Percentage

Yes 125 48.4 125 53.9

No 133 51.6 107 46.1

Reason for attempted

cessation of alcohol use

(n=125) (48.4%)

Reason for attempted cessation of

alcohol use (n=125)(53.9%)

Family

resistance

82(31.7%) 82(35.4%)

Adverse

effect

43(16.7%) 43(18.5%)

Among 258 ever alcohol users the 125(48.4%) had tried to stop alcohol use

of which 82(35.3%) is due to family resistance and 43(18.5%) due to adverse

effects of alcohol.

Among 232 current alcohol users the 125(53.9%) had tried to stop alcohol

use of which 82(35.3%) is due to family resistance and 43(18.5%) due to adverse

effects of alcohol.

5.5. DETERMINANTS OF EVER AND NEVER ALCOHOL USE:

BIVARIATE ANALYSIS:

To obtain the determinants of alcohol use, men were classified as ever

alcohol user and never alcohol user. Factors which were tested for association

were married, type of family , head of the family, others stay with you, morbidity,

awareness about alcohol, any alcohol user in the family, relation with the user,

whether current user, special source of alcohol, wife objects it, distance between

house and outlet, wine manufacturing in home, supply alcohol work place office,

place of alcohol consumption, reason for continuing alcohol use, measures to stop

alcohol, reason for cessation of alcohol, frequency of alcohol use, alcohol in

friends gathering and alcohol in social gathering .

Table 21: Factors Associated with alcohol use among ever and never alcohol

users

Factor

ALCOHOL USERS CHI SQUARE/

FISHERS

EXACT

p Value EVER NEVER

Type of family

Nuclear

Family

171

0

226.40

<0.001

Extended

family

82

206

Joint family 5 0

No family 0 0

Married

Married 230 90 146.27 <0.001

Divorced 0 89

Never

married

28 27

Widowed 0 0

Separated 0 0

Head of the

family

Yes 240 206 14.95 <0.001

No 18 0

Staying with

Children 0 0 100.48 <0.001

Wife 159 206

Parents 99 0

Alone 0 0

Awareness

about alcohol

0-14 188 89 <0.001

15-29 70 117

30-44 0 0

45-59 0 0

≥ 60 0 0

Morbidity

Yes 137 62 24.74 <0.001

No 121 144

Any alcohol

user in the

family

Yes 145 62 31.589 <0.001

No 113 144

Relation with

user

Son 145 62 31.58 <0.001

Family

relative

113 144

Specify 0 0

Whether a

current user

Yes 45 0 39.789 <0.001

No 213 206

Distance

between house

and outlet

Less than one

km

189 35 145.22 <0.001

More than

one km

69 171

Wine

manufactured

in home

Yes 19 0 15.818 <0.001

No 239 206

Special source

of alcohol

Abroad 126 42 42.44 <0.001

Military 40 50

Private shop 24 41

Others 68 73

Supplying

alcohol in

work place/

office

Yes 158 81 22.034 <0.001

No 100 125

Objection

from wife

Yes 200 61 106.82 <0.001

No 58 145

Supplying

alcohol in

gathering of

friends

Yes 163 91 16.69 <0.001

No 95 115

Supplying

alcohol in

social

gathering

Yes 32 0 27.44 <0.001

No 226 206

Place of

alcohol

consumption

House 57 9 238.30 <0.001

Restaurant 19 9

Friends home 71 11

Hide out 55 12

Social

gathering

0 0

Hostel 30 0

Others 26 165

Reason for

continuing

alcohol use

peer pressure 59 8 272.48 <0.001

withdrawal

symptoms

55 7

to work more 36 9

to get rid of

symptoms

33 6

maintain social

status

19 169

to get good

sleep 25 0

to get rid of

worries

17 0

Others 14 7

Attempts done

to stop alcohol

Yes 125 0 136.60 <0.001

No 133 206

Reason for

cessation of

alcohol

Family

resistance

82 0 79.52 <0.001

Side effects 43 0

Frequency of

alcohol use

One month or

less

54 0 222.28 <0.001

2 to 4 times a

month

65 0

2 to 4 times a

week

55 0

4 or 7 times a

week

84 206

Among this 21 variables were statistically significant. (p<0.001) (Table21).

Table 22: Factors Associated with alcohol use among ever and never alcohol

users- Odds (95%CI)

Factor

Odds

(95%CI)

p Value

Head Of The Family 1.858(1.705,2.025) <0.001

Staying with others 0.436(0.388,0.490) <0.001

Alcohol user 8.923(6.212,12.818) <0.001

Morbidity 2.630(1.789,3.866) <0.001

Alcohol User In The Family 2.980(2.026,4.385) <0.001

Current User 1.967(1.790,2.161) <0.001

Distance Between House And Outlet 13.383(8.479,21.121) <0.001

Wine Manufactured In Home 1.862(1.708,2.030) <0.001

Wife Objects alcohol use 8.197(5.395,12.453) <0.001

Supplies Alcohol In Friends

Gathering

2.168(1.492,3.151) <0.001

Supplies Alcohol In Social Gathering 1.912(1.747,2.092) <0.001

Attempts to Stop Alcohol 2.549(2.233,2.910) <0.001

Reason for Cessation of Alcohol 2.170(1.947,2,419) <0.001

The association between factors associated with alcohol use among ever

and never alcohol users and ‘distance between house and outlet’was statistically

significant (p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘current user’ was statistically significant (p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘head of the family’ was statistically significant

(p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘alcohol user in the family’ was statistically significant

(p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘morbidity’ was statistically significant (p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘wife objects alcohol use’ was statistically significant

(p<0.001).

The association between factors associated with alcohol use among ever

and never alcohol users and ‘supply of alcohol in social gathering’ was statistically

significant (p<0.001).

DETERMINANTS OF EVER AND NEVER ALCOHOL USE:

MULTIVARIATE ANALYSIS

All the variables significant in bivariate analysis were included in binary

logistic regression analysis. but no factors were statistically significant in

predicting alcohol use independently.

5.6 DETERMINANTS OF CURRENT ALCOHOL USE: BIVARIATE

ANALYSIS

To obtain the determinants of alcohol use, men were classified as current

alcohol user and current non alcohol user. factors which were tested for association

were religion, others who stay with, any chronic disease, morbidity, morbidity

duration, smoking, alcohol users in the family ,whether current user, number of

current alcohol users in the family, any alcoholics in work place, distance between

home and outlet, supply alcohol in family, parents objects it, wife objects it, supply

of alcohol in work place, outlet open in holidays, object liquor in office by

superiors, object liquor in friend gathering, supply of alcohol in social gathering,

object for liquor by colleagues, outlet open on working days, alcoholic in social

circles, anybody forced, anything done to stop alcohol, the reason for cessation of

alcohol

Use, object for liquor by colleagues, frequency of alcohol use, any alcoholic

in close circles.

Table 23: Factors associated with alcohol use among current alcohol users

VARIABLES

CURRENT

ALCOHOL

CHI

SQUARE/

FISHERS

EXACT

p

VALUE USERS

NON

USERS

Religion

Christian 74 26 45.684 <0.001

Hindu 77 0

Muslim

81

0

Others Who Stay With

You

Wife 133 26 18.003 <0.001

Parents

99

0

Any Chronic Disease Yes 96 26 32.23 <0.001

No 136 0

Morbidity Yes 111 26

25.537 <0.001

No 121 0

Morbidity Duration

Ten Years 66 10 31.918 <0.001

Five Years 45 16

Nil 121 0

Smoking Yes 88 26 36.523 <0.001

No 144 0

Alcohol Users In The

Family

Yes 119 26 22.533 <0.001

No 113 0

Is He A Current User

Yes

29 16

39.045 <0.001

No

203 10

How Many Current

Alcohol Users In The

None 110 0 48.792 <0.001

One 52 0

Family Nil 70 26

Any Alcoholics In

Work Place

Yes 61 24 46.121 <0.001

No 171 2

Distance Between

Home And Outlet

Less Than

1 Km 189 0

79.199 <0.001

More Than

1 Km 43 26

Supply Alcohol In

Family

Yes 123 26 21.152 <0.001

No 109 0

Parents Objects alcohol Yes 142 26 15.490 <0.001

No 90 0

Wife Objects alcohol Yes 174 26 8.385 <0.001

No 58 0

Supply Of Alcohol In

Work Place

Yes 132 26 18.300 <0.001

No 100 0

Outlet Open In

Holidays

24 Hours 62 26 55.85 <0.001

Day Time

Only 55 0

Night

Time Only 55 0

Specific

Timings 60 0

Superiors

object Liquor In Office

Yes 132 26 18.300 <0.001

No 100 0

Friends Object Liquor

In Friend Gathering

Yes 142 26 15.490 <0.001

No 90 0

Supply Of Alcohol In

Social Gathering

Yes 23 9 13.130 <0.001

No 209 17

Colleagues Object

Liquor

Yes 189 0

79.19 <0.001

No 43 23

Outlet Open On

Working Days

24 Hours 62 26 55.85 <0.001

Day

Timings 55 0

Night

Timings 55 0

Specific

Timings 60 0

Alcoholic In Social

Circles

Yes 61 24 46.121 <0.001

No 171 2

Any Force from others Yes 37 23

68.881 <0.001

No 195 3

Attempts to Stop

Alcohol

Yes 125 0 27.175 <0.001

No 107 26

Reason For Cessation

Of Alcohol

Health

Problem 82

0

0

13.471 <0.001

Family

Resistance 43 0

Colleagues object

Liquor

Yes 142 26 15.49 <0.001

No 90 0

Frequency Of Alcohol

Use

Less Than

A Month 54 0

26.491 <0.001

2 To 4

Month 65 0

2 To 4

Week 47 8

4 Or 7

Times A

Week

66 18

Any Alcoholic In Close

Circles

Yes 37 23 68.881 <0.001

No 195 3

Among this 28 variables were statistically significant (p<0.001) (Table 23).

Table 24 : Factors associated with alcohol use among current alcohol users-

Odds (95%CI)

Factor Odds

(95%CI) pValue

Any chronic disease 0.836(0.717,0.863) <0.001

Others Stay With you 0.787(0.781,0.896) <0.001

Smoking 0.772(0.699,0.853) <0.001

Morbidity 0.810(0.747,0.879) <0.001

Any Alcohol User In The Family 0.821(0.761,0.886) <0.001

Is he Current User 0.89(0.037,0.215) <0.001

Alcoholic in social circles 0.030(0.007,0.130) <0.001

Distance between house and

outlet

1.605(1.336,1.928) <0.001

Supply of alcohol in family

function

0.826(0.767,0.889) <0.001

Parents objects it 0.845(0.792,0.902) <0.001

Wife objects it 0.870(0.825,0.918) <0.001

Supply of alcohol in work place 0.835(0.780,0.895) <0.001

Object for liquor by superiors 0.835(0.780,0.895) <0.001

Object for liquor by friends 0.845(0.792,0.902) <0.001

Supply of alcophol in social

gathering

0.208(0.083,0.519) <0.001

Object for liquor by collegues 1.605(1.336,1.928) <0.001

Any body forced you 0.025(0.007,0.087) <0.001

Object for liquor by collegues 1.605(0.792,0.902) <0.001

Anything done to stop alcohol 1.243(1.143,1.352) <0.001

If yes what is the reason for

cessation of alcohol

1.173(1.103,1.248) <0.001

Alcoholic in close circles 0.025(0.007,0.087) <0.001

The association between factors associated with alcohol use among current

alcohol users and ‘distance between house and outlet’ was statistically significant

(p<0.001).

The association between factors associated with alcohol use among current

alcohol users and ‘object for liquor by collegues’ was statistically significant

(p<0.001).

The association between factors associated with alcohol use among current

alcohol users and ‘anything done to stop alcohol’ was statistically significant

(p<0.001).

DETERMINANTS OF CURRENT ALCOHOL USE: MULTIVARIATE

ANALYSIS

All the variables significant in bivariate analysis were included in binary

logistic regression analysis and no factors were statistically significant in

predicting alcohol use independently.

5.7 DETERMINANTS OF ALCOHOL DEPENDENCE: BIVARIATE

ANALYSIS

To obtain the determinants of alcohol dependence, AUDIT score were

classified as of less than 7 and more than 7 factors which were tested for

association were religion, marital status ,education, occupation, type of family,

others stay with you ,any chronic disease, , morbidity, morbidity duration smoking,

awareness about alcohol, any alcohol user in the family, your relation with user, is

he a current user, how many current alcohol users in family, alcoholics in your

work place, alcoholics in your social circle ,distance between your house and

outlet, outlet open working day, outlet open holidays, type of outlet, special source

alcohol, supply alcohol family function, parents object it, wife objects it, supply

alcohol work place office, object liquor in office function by superiors, supplies

alcohol in friends gathering, supplies alcohol in social gathering, object liquor by

colleagues group in social gathering, anybody forced you to consume alcohol,

alcoholic in close circles, with whom you drink, anything done to stop alcohol, if

yes what is reason for cessation of alcohol, object liquor by colleagues, frequency

of alcohol use.

Table 25: Factors associated with alcohol dependence among current users

FACTOR

VARIABLES

AUDIT

≤ 7(%)

AUDIT

≥ 8(%)

CHI

SQUARE/

FISHERS

EXACT

pVAL

UE

Religion

Christian 74 0 149.57

<0.001 Hindu 4 73

Muslim 23 58

Others 0 0

Marital status

Married 101 103 24.551 <0.001

Unmarried 0 28

Widowed 0 0

Divorced 0 0

Separated 0 0

Education

Illiterate 28 0 190.45 <0.001

Primary school

certificate

29 0

Middle school

certificate

29 0

High school

certificate

0 64

Higher secondary 0 35

Graduate or post

graduate

15 32

Occupation

un employed 66 0 224.131 <0.001

Un skilled 33 0

Semiskilled 2 59

Skilled 0 23

Clerical/shop

owner/farmer

0 22

Semi professional 0 12

Professional 0 15

Others stay

with you

Spouse 2 131 223.98 <0.001

Parents and

children

99 0

Others 0 0

Any chronic Yes 89 7 161.09 <0.001

disease No 12 124

Morbidity Yes 101 10 194.98 <0.001

No 0 121

Morbidity

duration

Nil 0 121 197.48 <0.001

5 years 45 0

10 years 56 10

Smoking Yes 88 0 183.89 <0.001

No 13 131

Any alcohol

user in the

family

Yes 101 18 169.85 <0.001

No 0 113

Your relation

with user

Son 22 0 172.36 <0.001

Relative/family

member

79 18

Specify 0 113

Is he a current

user

Yes 22 7 14.09 <0.001

No 79 124

How many

current alcohol

users in the

family

Nil 31 79 141.43 <0.001

One 0 52

Two 70 0

Alcoholics in

your work

place

Yes 54 7 68.146 <0.001

No 47 124

Alcoholics in

your social

circle

Yes 54 7 68.14 <0.001

No 47 124

Distribution

between your

house and

outlet

Less than one km 101 88 40.69 <0.001

More than one km 0 43

Outlet open

working day

24 hours 54 8 175.84 <0.001

Only in the

morning

47 8

Only in the night 0 55

Specific timings 0 60

Outlet open

holidays

24 hours 54 8 175.84 <0.001

Only in the

morning

47 8

Only in the night 0 55

Specific timings 0 60

Type of outlet

Govt bar 54 8 175.84 <0.001

Private bar 47 8

Private bar with

restaurant

0 55

Others 0 60

Special source

alcohol

Abroad 100 0

228.03

<0.001

Military 1 39

Private shop 0 24

Others 0 68

Supply alcohol

family function

Yes 101 22 158.51 <0.001

No 0 109

Parents object

it

Yes 101 41 113.36 <0.001

No 0 90

Wife objects it Yes 101 73 59.62 <0.001

No 0 58

Supply alcohol

work place

office

Yes 101 31 135.50 <0.001

No 0 100

Object liquor in

office function

by superiors

Yes 101 31 135.50 <0.001

No 0 100

Supplies

alcohol in

friends

gathering

Yes 101 42 111.32 <0.001

No 0 89

Supplies

alcohol in

social gathering

Yes 15 8 4.88 <0.001

No 86 123

Object liquor

by collegues

group in social

gathering

Yes 101 88 40.69 <0.001

No 0 43

Any body

forced you to

consume

alcohol

Yes 29 8 21.74 <0.001

No 72 123

Alcoholic in

close circles

Yes 29 8 21.74 <0.001

No 72 123

With whom

you drink

Alone 40 0 157.84 <0.001

Friends 0 20

Relative 61 26

Spouse 0 20

Others/specify 0 65

Anything done

to stop alcohol

Yes 101 24 153.11 <0.001

No 0 107

Reason for

cessation of

alcohol

Family resistance 82 0 164.49 <0.001

Get rid of side

effects

19 0

Object liquor

by colleagues

Yes 41 101 113.36 <0.001

No 90 0

Frequency of

alcohol use

One month or less 54 0 118.75 <0.001

2 to 4 times a

month

32 33

2 to 4 times a

week

0 47

4 or 7 times a week 15 51

Among this 37 factors were statistically significant. (p<0.001) (Table 25)

Table 26: Factors associated with alcohol dependence among current users-

Odds (95%CI)

Factor Odds Ratio

(95%CI)

p value

Marital status

0.505(0.441,0.578) <0.001

Others stay with you 0.015(.004,0.060) <0.001

Any chronic disease 131.38(49.74,346.95) <0.001

Morbidity 0.090(0.050,0.163) <0.001

Smoking 11.077(6.595,18.603) <0.001

Any alcohol user in the family 0.151(0.099,0.232) <0.001

Is he a current user 4.933(2.013.12.086) <0.001

Alcoholics in your work place 20.353(8.647,47.901) <0.001

Distance between your house and

outlet 0.466(0.400,0.0542) <0.001

Supply alcohol family function 0.179(0.122,0.261) <0.001

Parents object 0.289(0.223,0.374) <0.001

Wife objects 0.420(0.352,0.500) <0.001

Supply of alcohol in work place 0.235(0.173,0.320) <0.001

Alcoholics in social circle 20.353(8.647,47.901) <0.001

Object liquor in office function by

superiors 0.235(0.173,0.320) <0.001

Supplies alcohol in friends gathering 0.294(0.228,0.379) <0.001

Supplies alcohol in social gathering 2.682(1.089,6.604) <0.001

Object liquor by colleagues group in

social gathering 0.466(0.400,0.542) <0.001

Anybody forced to consume alcohol 6.193(2.687,14.273) <0.001

Alcoholic in close circles 6.193(2.687,14.273) <0.001

Reason for cessation of alcohol 7.895(5.186,12.018) <0.001

Object for liquor by colleagues 0.289(0.223,0.374) <0.001

Object liquor by colleagues group in

social gathering

0.466(0.400,0.542) <0.001

Anybody forced you 6.193(2.687,14,273) <0.001

Anything done to stop alcohol

consumption

0.192(0.134,0.275) <0.001

The odds of developing alcohol dependence is 131 times higher among

those who have chronic disease compared to that of those who do not have chronic

disease.

The odds of developing alcohol dependence are 11 times higher among

smokers compared to that of non smokers.

The odds of developing alcohol dependence are 4.9 times higher among

current users in family compared to that of non current users in the family.

The odds of developing alcohol dependence is 20 times higher among those

who have alcoholics in their work place compared to that of those who do not have

alcoholics in their work place.

The odds of developing alcohol dependence is 20 times higher among those

who have alcoholics in their social circle compared to that of those who do not

have alcoholics in their social circle.

DETERMINANTS OF ALCOHOL DEPENDENCE: MULTIVARIATE

ANALYSIS

When all the significant variables of bivariate analysis were subjected to

binary logistic regression, no factors were found statistically significant.

6. DISCUSSION

A cross-sectional study was done with the primary objective to estimate the

prevalence of alcohol use among men aged 18 and above in the Thiruvattar block,

Kanyakumari District, Tamilnadu using AUDIT questionnaire, administered by

the researcher after getting informed consent. Associated social factors were also

studied. The findings of this study provide insight into the burden of alcohol use

and the social factors associated with it.

We have done a cross sectional study for estimating the prevalence of

alcohol use in Thiruvattar block as the primary objective. Associated social factors

were also found out. The prevalence of current alcohol use among men for the

state of Tamilnadu was 46.7%8. The national prevalence of alcohol use in India

was 29.2% according to NFHS-48.The prevalence among men population in

Thiruvattar Block was generally considered high. So assuming a minimum

prevalence of 46.7% which is the state prevalence, sample size was calculated.

Two stage Sampling Technique was used. One ward out of 15 wards from each of

the 16 panchayats in Thiruvattar block was selected randomly by lottery method

to ensure adequate representation. In the Second Stage, the houses enlisted from

the selected ward, of panchayat was used as the sampling frame. 32 houses were

chosen by computer generated random number method. From the selected houses

one male adult subject was chosen for the study. If there was more than one man

in the house, one of them was chosen by lottery method. If no man was present in

the house, the next house chosen by random number technique and was visited.

Thus a sample of 464 men satisfying the inclusion and exclusion criteria was

studied.

Alcohol consumption is difficult to quantify due to various reasons like

frequency and type of beverage consumed, quantity of alcohol used, and alcohol

concentration. Data collection was done using a pretested questionnaire including

WHO endorsed tool AUDIT [Alcohol use Disorder Identification Test] to quantify

alcohol consumption and alcohol use disorder.

Our study revealed that 12.7% did not have any formal education, giving an

effective literacy rate of 87.3%. Literacy rate of Tamilnadu as per 2011 census was

80.33% and Male Literacy rate was 86.81 %79. India‘s literacy rate was 74.04%

and male literacy rate was 82.14%79. Comparing with this, the literacy rate of men

in Thiruvattar block was found higher than the national average Government of

India sees education as one of the best tools in helping general population.

Among 464 study participants (23.3%) of our study participants were

unemployed and 70(15.1%) of them were un skilled (Domestic Servant, Peon,

Watchman)and 108(23.3%) of them were skilled(Driver, Telephone Operator,

Manson, Carpenter) and 43(9.3%) of them were clerical and 22(4.7%) of them

were semi-profession(High School Teachers, College Lecturers, Junior

Administrators), and 30(6.5%) of them were professionals (Doctors, Advocates,

Engineers, Architects, Directors, Managers, Senior Administrators, News Paper

Editors, College Principals, Bank Managers). As Thiruvattar block consist of many

manual labourers, the skilled participants was 108((23.3%) is very high.

The mean monthly family income of the study participants was 12983.26.

This could be an under estimation of the fact that it is self-reported. This might be

due to the incentives they were currently availing. Also, there is a general tendency

among humans not to reveal their true income from various sources. The daily

wage offered for manual labourer varied from Rs. 500 to 1000.

As per modified Kuppuswamy classification 9(1.9%) belong to lower class,

146(31.5%) belong to upper lower class, 228(49.1%) belong to lower middle class,

77(16.6%) belong to upper middle class, 4(0.9%) belong to upper class.

The median age of initiation of alcohol use in our study among ever users

was 24 years and mean age was 24.32 years, the minimum being 18 years and

maximum being 31 years. Younger persons have began to drink and percentage of

those who were aged below 21 years taking drinks has increased from 2 % to more

than 14 % in the past 15 years. The average age of initiation has dropped from 19

years to 13 years in the past 20 years81. In a study done by Ganesh kumar et al at

vanur taluk in villupuram district Tamilnadu among 1000 people the mean age of

initiation was found to be 25.3 years (SD 9.0)24,80. In another study done in a

Kolkata slum, the mean age of initiation of drinking alcohol was 20.8 years32 .In

our study, among 258 ever users the friends were the first source for initiating the

alcohol consumption for 69 (26.7%) of alcohol users, followed by curiosity for 64

(24.8%) of them. In another study done comparing Kerala and Arunachal Pradesh

college men, most of the male students in Arunachal Pradesh initiated with a

family member (63.3 percent) while some with friends (32.9 percent) . In Kerala,

most of them initiated with their friends (74.8 percent), and only some with family

members (24.5 percent)the special source of alcohol supply was from abroad

126(48.8%)and next source from military 10(15.5%) and the others 68(26.4%)81.

The prevalence of alcohol use in men aged 18 years and above in our study

was 55.6% with a 95% confidence interval of 51.07 to 60.12 for ever alcohol use.

The prevalence of current alcohol use was 50 % with a 95% confidence interval of

54.54 to 45.45. According to NFHS-4 in 2015-16, percentage of men who

consume alcohol in Tamilnadu was 46.7%8, The prevalence of current alcohol use

among men aged 18 years and above in Thiruvattar block (50%) was almost

similar to prevalence of alcohol use among men in the Tamilnadu. In India, among

men, prevalence of alcohol use was found to be 29.2%. This high prevalence of

50% in Thiruvattar block is alarming. In a study conducted in 2012 at rural area of

Tamilnadu by Ruma Dutta et al the prevalence of alcoholism among the study

participants was 35.7%82.

In a study conducted in May 2012 to march 2013 at rural pudhucherry by

Vijay Ramanan, the overall prevalence of alcohol use among ≥18 years of age was

9.7% and exclusively among males was 17.1%. the highest prevalence (17.1%)

was among 46–55 years age groups and the residents of joint families (37.0%)67.

In an epidemiological study in urban area conducted from october 2008 to

september 2009 by Arun kumar Pandey, the prevalence of alcohol abuse was

found to be 9.48%83.In a study conducted in urban slums of southern India from

December 2010 to May 2011 by Sinmin kim among all men, it was estimated

that 46.1% consumed alcohol and 31.4% were hazardous drinkers (19% increased-

risk, 7.7% high-risk and 4.7% dependent drinkers)84. In a study conducted in

Thiruvananthapuram district, Kerala from 1st april to 31st may, 2014 by Rakshase

bal, the alcohol dependence among males in Thiruvananthapuram was as high as

38.41%48. A study conducted by Jaisoorya et al on alcohol use among adolescents

in Ernakulam, Kerala State found out that the overall prevalence of lifetime

alcohol use among adolescents was 15% (23.2% among boys and 6.5% among

girls). The prevalence was increasing with age, and 25.3% of drinkers reported to

have hazardous alcohol use85.

The prevalence in this age group could also be an underestimation as

adolescents might not disclose their alcohol status due to fear of parents knowing it

and getting scolded or punished.

The prevalence of alcohol use disorder obtained in our study was 28.23%

with a 95% confidence interval of 19.67 -36.78.

In a population-based cross-sectional survey was conducted by Emilene Reisdorfer

et al among adults (20 to 59 years) in a medium-sized city in southern brazil the

prevalence of alcohol use disorders in the population was 18.4%86.

Comparing with the studies, the prevalence of alcohol use disorder in Thiruvattar

block among men (28.23%) was very high and needs to be noticed, especially the

age group of 40-49 years which had an alcohol use disorder prevalence of 37.4%.

A cross-sectional study was undertaken by Rajendra Harnagle et al in an

urban community of the various wards of Jabalpur Cantonment in India shows

that among 3586, about 434 (12.10%) were found to have a Alcohol dependence

syndrome (ADS)56.

In a study done among males more than 18 years of age in a Kolkata slum

by Santanu Ghosh , 65.8% were current users of alcohol,14% were alcohol

dependents,8% were hazardous or harmful users32.In our study the prevalence of

those who should be assessed for dependence among current alcohol users was

obtained as 31.03 % with a confidence interval of 26.82 – 35.23.Comparable to

other studies the prevalence of alcohol dependence in Thiruvattar block was high.

Age plays a vital role in assessing the prevalence of alcohol use. Our results

revealed that 55.6 % of our sample was ever alcohol users and 50% were current

alcohol users and 28.23% had alcohol use disorder. 20.5% of subjects in the age

group of 40-49 years were ever alcohol users and 22.8% were current alcohol users

and 37.4% were showing alcohol use disorder. Only 23.2% in the age group of 18-

29 years were ever alcohol users which give us an opportunity to control alcohol

use in future, if adequate measures are taken by the Government and local

governing bodies to catch them young. A cross-sectional survey done by Beauty

Mahanta et al among school-going adolescent students in an industrial town of

Assam showed that the majority of the students that 36% out of 1285 students had

tasted/ homemade alcoholic drinks (HADs) and 12.3% used commercially

available alcoholic drinks (CADs)87.

In our study out of 258 ever alcohol study participants 51% used whisky

and 42% used rum and 32% used beer and 42 % used brandy Toddy was not

tapped due to prohibition on production of alcohol but as our state is near to Kerala

about 25 % of them use toddy. This could be due to fear as they know producing

toddy is illegal. In our study out of the 232 current alcohol users, 23.7% procured

alcohol from private outlet just beyond Kerala-Tamil Nadu border while they go

for work and this showed significant association with having alcohol use disorder.

The money earned by people of Thiruvattar block was also found flowing to

Kerala through private alcohol shops in Kerala.

Nearly 55.4% of the study subjects in the present study was of the opinion

that there was no history of alcohol use in the family. There could also be a

reluctance to say the truth due to social desirability and a possible social stigma.

In our study the ‘Alcohol users in the family’ was found to be a statistically

significant risk factor for current alcohol users. Our study found out that the family

with alcohol users were consuming more alcohol 119(51.29%)

Prevalence of current smoking was 36.2% in our study .The prevalence of

smoking in Thiruvattar was higher than the prevalence of smoking (31.7% ) in

Tamilnadu8. In India according to NFHS-4 it was 39.2% 8.

In our study the ‘education status’ was a statistically significant risk factor

for alcohol dependence as our study found out that those having high school

certificate (64(48.85%) )were under alcohol dependence as these students could

join in bad company and become addicted to alcohol due to various reasons like

broken family, peer pressure ,love failure, failure in exams comparing to study

done by Shasi Prabha Tomar et al done among 214 villagers in Mandla district

Madhya Pradesh reveals that alcohol consumption was more prevalent among

illiterate (6.7%) 88.

In our study the ‘occupation’ was a statistically significant risk factor for

alcohol dependence as our study found out that majority of the unemployed were

under low risk of alcohol dependence 66(65.34%) followed by semi skilled

59(45.03%) were under alcohol dependence . This might be because the un

employed did not have money to buy alcohol and the semi skilled workers

consume alcohol due to various reasons like body pain,problem family,bad

company comparing to study done by Rakshase Bal et al conducted among 302

people at Thiruvanan tha puram found that un employment is significantly

associated with alcohol dependence48.

In our study the ‘Any chronic disease’ was s a statistically significant risk

factor (p<0.001) for alcohol dependence as our study found out that those who

did’t have any chronic disease were alcohol dependents 124(94.65%) . As those

who did not have chronic problems were healthy and they were likely to consume

more alcohol.

In our study the ‘Outlet open on working day’ was a statistically significant

risk factor(p<0.001) for alcohol dependence as our study found out that majority

of them 60(45.80%) who follow specific timings were alcohol dependence as some

people who would come after work consume alcohol before going to their home

due to reasons like body pain.

In our study the ‘Supply of alcohol in family functions’ was a statistically

significant risk factor(p<0.001) for alcohol dependence as our study found out that

alcohol dependence was more among persons where the supply of alcohol in

family function 195(84.05%).In our study the ‘Parents objects it’ is a statistically

significant risk factor for alcohol dependence(p<0.001) as our study found out that

majority of the persons were low risk 101(100%) followed by those whom parents

had not objected were alcohol dependent. 90(68.70%).

In our study the ‘Object for liquor in office function by superiors’ was a

statistically significant risk factor(p<0.001) for alcohol dependence as our study

found out that majority of them were low risk 101(100%) followed by those who

had no objection for liquor in office function by superiors were alcohol dependent

100(76.33%). In our study the ‘anything done to stop alcohol’ was a statistically

significant risk factor(p<0.001) for alcohol dependence as our study found out that

majority of them who had not done anything to stop alcohol were alcohol

dependent 107(81.67%). In our study the ‘Frequency of alcohol use’ was a

statistically significant risk factor(p<0.001) for alcohol dependence as our study

found out that majority of them were low risk 101(100%) one month or less

followed by 51(50.49%) for whom the frequency of alcohol use was 4 or 7 times a

week and were alcohol dependent. .In our study the ‘Others who stay with ’ was a

statistically significant risk factor(p<0.001) for current alcohol users as our study

found out that alcohol consumption was less among those who stay with parents

99(42.67%).In our study presence of ‘Any chronic disease’ was a statistically

significant risk factor(p<0.001) for current alcohol users as our study found out

that alcohol consumption was less among those who have morbid illness like

diabetes ,hypertension as these people would be un healthy and so they would

avoid alcohol 136(58.62%) comparing to a study done by Ganesh kumar et al in

rural Tamilnadu done among 946 subjects showed that presence of chronic

diseases was significantly associated with alcohol use24.

In our study the ‘Distance between house and outlet’ was a statistically

significant risk factor(p<0.001) for current alcohol users as our study found out

that if the distance was less than 1 km then alcohol consumption was more

189(81.46%).In our study the ‘Supply of alcohol in the family function’ was a

statistically significant risk factor(p<0.001) for current alcohol users as our study

found out that if there was supply of alcohol in the family function then alcohol

consumption was more among them 123(53.01%).In our study the ‘Supply of

alcohol in work place’ also was a statistically significant risk factor(p<0.001) for

current alcohol users as our study found out that if there was supply of alcohol in

the work place then alcohol consumption was more among them 132(56.89%).In

our study the ‘Outlet open on holidays’ was a statistically significant risk

factor(p<0.001) for current alcohol users as our study found out that if the outlet

was open for 24 hours then alcohol consumption was more among them as they

could go at any time and consume as much as they want 62(26.72%). In our study

the ‘Outlet open on working days’ was also a statistically significant risk

factor(p<0.001) for current alcohol users62(26.72%). In our study the ‘Frequency

of alcohol use’ was a statistically significant risk factor(p<0.001) for current

alcohol users as our study found out that if the frequency of alcohol use was 4 or 7

times a week then alcohol consumption was more among them 66(28.44%).In our

study the ‘Type of family’ was a statistically significant risk factor(p<0.001) for

ever and never alcohol users as our study found out that men in nuclear family

consuming more alcohol as they were dominant in the family 171(66.27%) which

is similar to the study done by Shashi Prabha Tomar et al among 214 villagers in

Mandla district Madhya Pradesh showed that alcohol consumption was more in

nuclear families88.

In our study the ‘married’ is a statistically significant risk factor(p<0.001)

for ever and never alcohol users as our study found out that alcohol consumption

was more among those men who are married 230(89.14%) as they were dominant

and decision makers in the family comparing to study done by Rakshase bal et al

conducted among 302 people at Thiruvanan tha puram found that marital

disharmony was significantly associated (P<0.05)with alcohol dependence. In our

study the ‘head of the family’ was a statistically significant risk factor for ever and

never alcohol users as our study found out that alcohol consumption was more

among those who were the head of the family 240(93.02%) as they go for job and

spent the money for buying alcohol. The present study found out that alcohol

consumption was less among those who stay with their wife 206(100%). In our

study the ‘any alcohol user in the family’ is a statistically significant risk

factor(p<0.001) for ever and never alcohol users as our study found out that those

who have alcohol user in the their family the alcohol consumption was more

145(56.20%) as both of them drink they used to go and drink together. In our

study the ‘your relation with the user’ is a statistically significant risk

factor(p<0.001) for ever and never alcohol users as our study found out that if the

user is son then alcohol consumption among them is more 145(56.20%) as they

together will go for work or share money and their problems and consume alcohol.

In our study the ‘Distance between your house and outlet’ is a statistically

significant risk factor(p<0.001) for ever and never alcohol users as our study

found out that if the distance is less than 1 km then alcohol consumption is more

189(73.25%) .In our study the ‘Wine manufacturing at home’ is a statistically

significant risk factor(p<0.001) for ever and never alcohol users as our study

found out that if the wine is not manufactured at home then alcohol consumption

were more among them 239(92.63%) .

In our study the ‘Special source of alcohol’ is statistically significant risk

factor (p<0.001) for ever and never alcohol users as our study found out that

alcohol is obtained from abroad then alcohol consumption were more among them

126(48.83%).In our study the ‘Supply of alcohol in work place/office’ was a

statistically significant risk factor(p<0.001) for ever and never alcohol users as our

study found out that if the supply of alcohol in work place /office is there then

alcohol consumption was more among them 158(61.24%) as they drink with

them. In our study the ‘Supply of alcohol in friends gathering’ is statistically

significant risk factor for ever and never alcohol users as our study found out that

if there is supply of alcohol in the friends gathering then alcohol consumptionwere

more among ever users 163 (63.17%) . In our study the ‘Place of alcohol

consumption’ is a statistically significant risk factor(p<0.001) for ever and never

alcohol users as our study found out that majority of the ever alcohol users use

their friends home as the place of alcohol consumption 71(27.51%) as they

consider it safe and comfortable. In our study the ‘Reason for continuing alcohol

use’ was a statistically significant risk factor (p<0.001) for ever and never alcohol

users as our study found out that majority of the ever alcohol users are continuing

the alcohol use due to peer pressure 59(22.86%) as the friends will compel him to

drink or they will not join him in their company .

In our study the ‘Anything done to stop alcohol’ is statistically significant

risk factor (p<0.001) for ever and never alcohol users as our study found out that if

nothing was done to stop alcohol use then alcohol consumption were more among

ever users 133(51.55%).

STRENGTHS OF THE STUDY:

The use of a WHO formulated tool AUDIT in quantifying the alcohol

consumption Single researcher doing the whole data collection ensures uniformity

and avoids bias due to multiple researchers.

The methodology and reporting of this study has been adhered to STROBES

guidelines

EXTERNAL VALIDITY:

1. GENERALIZABILITY: This study can be very well generalized to

Thiruvattar block male population as the sample is representative.

2. CONCEPT TILTING: The findings of this study can be sent to State

authorities and central authorities including Ministry of health and family welfare.

This study provides data on the prevalence, reasons and factors associated with

alcohol use, which in turn would facilitate policy makers in charting out and

implementing effective prevention strategies.

3. UTILITY: This study creates baseline evidence, thus enabling the authorities to

focus on those factors and reasons responsible for high prevalence and to initiate

proper monitoring and evaluation.

4. PUBLIC HEALTH SIGNIFICANCE:

The main strategy should be focusing on de-addiction and also decreasing the

demand for alcohol. In Thiruvattar block, the awareness about de-addiction and

harmful effects of alcohol is also low and there is a need for creating awareness as

population of Thiruvattar block is also very much vulnerable to be influenced by

giving alcohol during elections and festival seasons.

7. SUMMARY AND CONCLUSION

This cross sectional survey carried out among 464 men aged above 18 years

of Thiruvattar block in Kanyakumari district, Tamilnadu estimated a high

prevalence of alcohol use (55.6% ).

Most of the current alcohol users are in borderline scores of AUDIT.

Thirty point two percent (30.2%) of them were above the score of 8 (

hazardous drinking range ) . fourteen point two percent (14.2%) of men in this

study group were already alcohol dependent needing specialist care for alcohol

related harm. Alcohol use was most prevalent among the age group of less than

40 year old. Fourty three point five percent of the men who were alcoholic had

AUDIT score of 7 or less than that i.e. harm less zone of drinking. If consumption

in this group continues they get them self promoted for Harm full Zones.

The significant risk factors of alcohol use of (current, ever and never,

alcohol dependence) that is ( p<0.001) were ‘any alcohol user in the family’, ‘a

current user’, ‘supply of alcohol in social gathering/ friends gathering, in work

place’, ‘frequency of alcohol use’, ‘morbidity’, ‘distance between home and

outlet’, ‘objection from wife ’, ‘any attempts done to stop alcohol’, ‘if yes reason

for cessation of alcohol’.

8. LIMITATIONS

Consumption of alcohol could not be quantified due to variance in consumption,

quantity, frequency, and type of beverage.

Varying strength of alcohol concentration across the type of beverage also

add to the difficulty in quantifying it.

Due to the social norms in answering the questions of alcohol use reporting

bias among young adults occur.

There is a chance for re call bias regarding the age of initiation and the age

at which the participants first came to know about alcohol .

9. RECOMMENDATIONS

As there is a high prevalence of alcohol use among men in Thiruvattar

block, various public health measures should be taken to prevent alcohol abuse.

A. Specialist care and awareness regarding alcohol use:

The prevalence of hazardous alcohol use (30.2%) among current alcohol

users in Thiruvattar block could be an under estimation due to reporting bias.

Specialist care and deaddiction centres in the block are much needed to decrease

the alcohol related social and economic problems. The Thiruvattar block

community should be educated for the treatment of alcohol dependence through

the monthly clinics (psychiatry) in Community health centre of Thiruvattar block.

B. Strengthen the existing Legislation and policy related to alcohol:

The legal age of minimum 21 should be enforced for the sale of alcohol in

alcoholic outlets.

Random breath testing can be implemented for alcohol related offences in

drunken driving.

C. Availability/supply of alcohol:

Some of the significant risk factors of alcohol use (current, ever and never,

alcohol dependence) were availability/supply of alcohol in work place. Necessary

guidelines should be implemented through community participation and also strict

rules should be implemented in the work place.

D. Health education:

The general public, especially the men of Thiruvattar block should be

educated regarding Alcohol- related harms .

Early intervention regarding the risk of alcohol consumption and its

addiction can be conducted in monthly clinics in Thiruvattar block community

health centre.

Periodic screening for men who are working and attending community

health centre should be done.

Awareness about ill effects of alcohol use, emphasizing on de-addiction

should be conducted for all men, women and children. So it will be able to

decrease the interest in using alcohol and create desire to quit alcohol, thereby

reducing the demand for alcohol. So that ‘the alcohol user’ at home will quit

alcohol and his friends will prevent him from consuming more alcohol in friends

and social gathering, and also the frequency of alcohol use will also come down

preventing alcohol dependence.

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ANNEXURES I

ANNEXURE II

ABBREVATIONS

SL NO

ACRONYM EXPANSION

1 AA Alcoholics Anonymous

2 ADS Alcohol Dependence Syndrome

2 AFR WHO Region Of Africa

3 AMR WHO Region Of Americans

4 AUC Area Under Curve

5 AUD Alcohol Use Disorders

6 AUDIT Alcohol Use Disorder Identification Test

7 CADs Commercially available alcoholic drinks

8 CI Confidence Interval

9 CMD Common Mental Disorders

10 DALY Disability adjusted life years

11 EMR WHO eastern Mediterranean region

12 EUR WHO Region Of Europe

13 HADs Home made alcoholic drinks

14 MSSI Modified scale for suicidal ideation

15 NFHS National Family Health Survey

16 OPD Out Patient Department

17 OR Odds Ratio

18 PHC Primary Health Centre

18 PHQ Physical Health Quality

19 SD Standard Deviation

20 SEAR South East Asian Region

21 SES Socioeconomic Status

22 SLI Standard Living Index

23 SMAST Short Michigan Alcohol Screening Test

24 SPSS Statistical package for social sciences

25 SSI Scale For Suicide Ideation

26 TASMAC Tamil Nadu State Marketing Corporation

27 WHO World health Organization

28 WPR WHO western pacific region

ANNEXURE III

PARTICIPANTS CONSENT FORM

The details of the study have been explained to me in writing and the details

have been fully explained to me. I am aware that the results of the study may not

be directly beneficial to me but will help in the advancement of medical sciences. I

confirm that I have understood the study and had the opportunity to ask questions.

I understand that my participation in the study is voluntary and that I am free to

withdraw at any time, without giving any reason, without the medical care that will

normally be provide by the hospital being affected. I agree not to restrict the use of

any data or results that arise from this study provided such a use is only for

scientific purpose(s). I have been given an information sheet giving details of the

study. I fully consent to participate in the study titled ‘Prevalence and Social

Factors associated with alcohol use among adult Men in Thiruvattar’.

Serial No/Reference no :

Name of the Participant :

Address of the Participant :

Contact number of the Participant :

Signature/Thumb impression of the participant/Legal guardian

Witnesses :

1

Date :

Place :

ANNEXURE –VI

INTERVIEW SCHEDULE

1) Id no:

2) Age in completed years ?

3) Religion : 1)Christian 2)Hindu 3)Muslim 4) Others

4) Type of family? 1)nuclear 2)extended 3)joint 4)no family

5) Marital status : 1)Married 2)Divorced 3) Never married 4)Widowed 5)

Separated

6) Educational status: 1)illiterate 2) primary school certificate 3)middle

school certificate 4) High school certificate 5) PUC or higher secondary

6)Graduate or post graduate 7) Professional

7) Current Occupation: 1) unemployed 2) unskilled 3) semiskilled 4)skilled

5) clerical/shop owner/farmer 6) semiprofessional 7) Professional

8) Income:

9) Are you the head of the family? A) yes b)no

10) Number of family members? 1)1 2)2 3)specify

11) What is your source of income? 1)Pension 2)Farming/from land 3)Job 4)

Remittance 5)None 6) earning of someone else in the family 7) others,

specify

12) Who is the owner of your residence? 1)self 2)children 3) Rent 4)parents

13) Who are the others staying with you currently? 1)Children 2)Spouse 3)

parents 4)Alone

14) Any chronic disease or morbidity? a)yes b) no if yes type of

morbidity,duration?

15) Have you ever smoked tobacco ? a) yes b) no

16) At what age did you come to know about alcohol? 1)0-14 2)15-29 3)30-

44 4)45-59 5)>60

17) Have you ever consumed alcohol? a ) yes b) no

18) Do u currently consume alcohol? a) yes b) no

19) Any alcohol users in the family a) yes b) no

20) If yes relation of the user to responder 1)Son 2)family relative 3)specify

21) If yes is he a current user a) yes b) no

22) No. of current alcohol users in the family 1) none 2)1 c) 2

Begin the AUDIT by saying “Now I am going to ask you some questions

about your use of alcoholic beverages during this past year.”

23) How often do you have a drink containing alcohol? (0) Never [Skip to Qs

33-34](1) Monthly or less(2) 2 to 4 times a month(3) 2 to 3 times a

week(4) 4 or more times a week

24) How many drinks containing alcohol do you have on a typical day when

you are drinking? (0)1 or 2(1)3 or 4(2)5 or 6(3)7, 8, or 9(4)10 or more

25) How often do you have six or more drinks on one occasion?

(0)Never(1)Less than monthly(2)Monthly(3)Weekly(4)Daily or almost

daily Skip to Questions 9 and 10 if Total Score for Questions 25 and 26= 0

26) How often during the last year have you found that you were not able to

stop drinking once you had started? (0)Never(1)Less than

monthly(2)Monthly(3)Weekly(4)Daily or almost daily

27) How often during the last year have you failed todo what was normally

expected from you because of drinking? (0)Never(1)Less than

monthly(2)Monthly(3)Weekly(4)Daily or almost daily

28) How often during the last year have you needed a first drink in the morning

to get yourself going after a heavy drinking session? (0)Never(1)Less

than monthly(2)Monthly(3)Weekly(4)Daily or almost daily

29) How often during the last year have you had a feeling of guilt or remorse

after drinking? (0)Never(1)Less than

monthly(2)Monthly(3)Weekly(4)Daily or almost daily

30) How often during the last year have you been unable to remember what

happened the nightbefore because you had been drinking? (0)Never(1)Less

than monthly(2)Monthly(3)Weekly(4)Daily or almost daily

31) Have you or someone else been injured as a result of your drinking?

(0)No(2)Yes, but not in the last year(4)Yes, during the last year

32) Has a relative or friend or a doctor or another health worker been

concerned about your drink-ing or suggested you cut down? (0)No(2)Yes,

but not in the last year(4)Yes, during the last year

33) Any alcohol users in the work place 1) yes 2) no

34) Any alcohol users in the social circle 1) yes 2) no

35) Average distance of alcohol out let from your house 1)less than 1 km

2)more than 1 km

36) What time this out let will be open on working days a) 24hrs b)Day time

only c)night only d) specify timings

37) What time this outlet will be open on holidays a) 24hrs b)Day time only

c)night only d) Specify timings

38) What type of most common out let is that a) govt b)private bar c) private

bar in restaurant d) others

39) Will you prepare wine in your home a) yes b) no

40) Special source of alcohol a) abroad b) military camp c) private shop d)

others

41) Will there be supply of alcohol during family function at your house a) yes

b) no

42) Is there opposition for use of alcohol in your family by parents a) yes b) no

43) Is there opposition for use of alcohol in your family by spouse a) yes b) no

44) Will there be supply of alcohol during your office function a) yes b) no

45) Is there opposition of use of alcohol in office a) yes b) no

46) Will there be supply of alcohol during your friends gathering a) yes b) no

47) Is there any opposition of use of alcohol during friends gathering by any

friends a) yes b) no

48) Will there be supply of alcohol during social gatherings a) yes b) no

49) Is there any opposition for use of alcohol during social gathering by any

one among your group A) yes b) no

50) Has anyone forced to take alcohol ever a) yes b) no

51) Was anybody alcoholic in your close circles when you were young

a)neighbor b) relatives c) friends d) teacher 5)specify 6 none

52) Age of responders at first use of alcohol 1. less than and 15 2. 16-30 3. 31-

45 4.46-60 5. more than 60 6. none

53) The place of alcohol consumption a) home b) Restaurant c) friends place d)

hideout e)Social gathering f) hostel g) others/specify

54) With whom do you most commonly consume alcohol with a) alone b)

friends c) family member d) spouse e) others/specify

55) How frequently are you consuming alcohol ? How much?

1. less than a month 2. 2 to 4 month 3. 2 to 4 week 4.4 or 7 times a week

56) Reason for starting alcohol consumption a) curious b) peer pressure c)

curious +peer pressure d) to feel with the crowd e) to work more h) others

57) Reason for continuing alcohol consumption a) peer pressure b) withdrawal

symptoms c) ) to work more c) to work more d) to get rid of symptoms e)

maintain social status f) to get good sleep 7)to get rid of worries 8) others

58) Have you ever tried to stop alcohol consumption? 1)yes 2) no

59) If yes then what is the reason? 1 health problem 2 finance problem 3

none

60) Type of beverage usually consumed a) whisky b) rum c) beer d) toody e)

brandy f) others g) none

MASTER CHART

ANNEXURE : IX Sl

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FAM

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INC

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AN

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KIN

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AW

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TALC

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OR

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AM

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ENTS

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JEC

TIT

WIF

EOB

JEC

TSIT

1 18 3 3 1 1 1 5 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 18 3 3 1 1 1 7 3 4 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

3 18 3 2 1 1 1 5 3 4 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

4 18 3 1 1 1 1 5 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

5 38 3 3 1 1 1 4 7 1 3 1 1 1 9 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1

6 39 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

7 19 3 1 1 1 1 5 3 4 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

8 19 3 1 1 1 1 4 7 1 3 1 1 1 9 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1

9 39 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

10 19 3 1 1 1 1 3 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

11 20 3 1 1 1 1 3 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

12 20 3 1 1 1 1 3 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

13 48 3 2 1 1 1 6 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

14 46 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

15 45 3 2 1 1 1 5 7 1 3 1 1 1 9 1 1 1 2 2 1 1 1 1 2 1 1 1 1 1 1

16 44 3 1 1 1 1 5 7 1 3 1 1 1 9 1 1 1 2 2 1 1 1 1 2 1 1 1 1 1 1

17 35 3 2 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

18 34 3 1 1 1 1 2 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

19 33 3 2 1 1 1 6 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

20 32 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

21 31 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

22 22 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

23 23 3 1 1 1 1 4 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

24 24 1 1 1 1 1 5 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

25 25 1 1 1 1 1 5 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

26 26 1 1 1 1 1 3 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

27 27 1 1 1 1 1 5 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

SUP

PLY

ALC

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OLW

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KP

LAC

EO

FFIC

E

OB

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TLIQ

UO

RIN

OFF

ICEF

UN

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ON

BY

SUP

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RS

MASTER CHART

28 28 1 1 1 1 1 3 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

29 29 1 1 1 2 1 4 3 4 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

30 30 1 1 1 2 1 5 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

31 20 1 1 1 2 1 3 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

32 20 1 1 1 2 1 4 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

33 23 1 1 1 2 1 4 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

34 24 1 1 1 2 1 4 3 1 3 1 1 1 9 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

35 25 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

36 26 1 1 1 2 1 3 3 4 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

37 27 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

38 28 1 1 1 2 1 2 3 4 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

39 29 1 1 1 2 1 2 3 4 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

40 30 1 1 1 2 1 4 2 1 3 1 1 1 10 1 1 2 2 2 1 1 1 1 2 1 1 1 1 1 1

41 22 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

42 22 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

43 23 1 3 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

44 24 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

45 25 1 1 1 2 1 3 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

46 26 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

47 27 1 2 1 2 1 5 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

48 28 1 2 1 2 1 4 1 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

49 29 1 2 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

50 30 1 1 1 2 1 5 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

51 21 1 1 1 2 1 3 3 4 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

52 22 1 2 1 2 1 4 3 4 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

53 23 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

54 24 1 1 1 2 1 4 3 1 3 1 1 1 10 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1

55 25 1 3 1 2 1 5 3 1 3 1 1 1 10 1 1 2 1 1 1 2 2 2 2 1 1 1 1 1 1

56 26 1 1 1 2 1 3 3 4 3 1 1 1 10 1 1 2 1 1 1 2 2 2 2 1 1 1 1 1 1

57 27 1 2 1 2 1 5 3 1 3 1 1 1 10 1 1 2 1 1 1 2 2 2 2 1 1 1 1 1 1

58 28 1 1 1 3 1 3 3 1 3 1 1 1 10 1 1 2 1 1 1 2 2 2 2 1 1 1 1 1 1

59 29 1 1 1 3 1 3 3 1 3 1 1 1 10 1 1 2 1 1 1 2 2 2 2 1 1 1 1 1 1

60 30 1 1 1 3 1 3 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

61 21 1 1 1 3 1 3 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

62 22 1 1 1 3 1 4 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

63 23 1 1 1 3 1 4 7 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

64 24 1 1 1 3 1 4 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

MASTER CHART

65 25 1 2 1 3 1 7 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

66 26 1 2 1 3 1 6 3 4 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

67 27 1 1 1 3 2 4 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

68 28 1 1 1 3 2 4 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

69 29 1 2 1 3 2 5 3 1 3 1 1 1 10 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

70 30 1 1 1 3 2 3 3 4 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

71 21 1 1 1 3 2 3 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

72 22 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

73 23 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

74 24 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

75 25 1 1 1 3 2 6 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

76 26 1 1 1 3 2 2 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

77 61 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

78 62 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

79 63 1 1 1 3 2 2 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

80 64 1 1 1 3 2 5 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

81 52 1 1 1 3 2 3 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

82 52 1 2 1 3 2 7 3 4 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

83 52 1 2 1 3 2 5 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

84 52 1 2 1 3 2 5 3 4 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

85 52 1 1 1 3 2 4 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

86 52 1 1 1 3 2 5 3 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

87 52 1 2 1 6 2 6 3 4 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

88 52 1 2 1 6 2 3 7 1 3 1 1 1 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

89 52 1 1 1 6 2 4 3 1 3 1 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

90 30 1 1 1 6 2 3 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

91 52 1 2 1 6 2 6 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

92 52 1 1 1 6 2 4 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

93 52 1 1 1 6 2 3 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

94 52 1 1 1 6 2 4 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

95 52 1 2 1 6 2 6 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

96 52 1 1 1 6 2 4 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

97 52 1 1 1 6 2 5 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

98 52 2 1 1 6 2 4 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

99 52 2 1 1 6 2 2 3 1 3 2 1 2 11 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

100 30 2 1 1 6 3 2 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 1 1 1 1 1 1

101 21 2 1 1 6 3 4 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

MASTER CHART

102 52 2 1 1 4 3 4 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

103 52 2 1 1 4 3 4 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

104 52 2 1 1 4 3 5 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

105 52 2 1 1 4 3 3 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

106 52 2 1 1 4 3 2 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

107 52 2 1 1 4 3 2 7 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

108 52 2 1 1 4 3 3 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

109 52 2 1 1 4 3 4 3 1 2 2 1 2 12 1 1 2 2 2 1 2 2 2 2 2 1 1 1 1 1

110 40 2 1 1 4 3 5 3 1 2 2 1 2 12 1 1 2 2 2 1 3 3 3 2 2 1 1 1 1 1

111 31 2 1 1 4 3 2 3 1 2 2 1 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

112 32 2 1 1 4 3 5 7 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

113 33 2 2 1 4 3 5 7 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

114 34 2 2 1 4 3 5 7 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

115 35 2 1 1 4 3 3 3 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

116 36 2 1 1 4 3 2 3 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

117 37 2 2 1 4 3 4 3 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

118 38 2 2 1 4 3 7 7 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

119 39 2 2 1 4 3 6 3 1 2 2 2 2 12 1 1 2 2 2 1 3 3 3 2 2 2 1 1 1 1

120 40 2 1 1 4 3 4 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

121 31 2 1 1 4 3 4 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

122 32 2 1 1 4 3 4 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

123 33 2 1 1 4 3 4 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

124 34 2 1 1 4 3 5 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

125 35 2 1 1 4 3 5 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

126 36 2 1 1 4 3 4 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

127 37 2 1 1 4 3 3 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

128 38 2 1 1 4 3 3 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

129 39 2 1 1 4 3 2 3 1 2 2 2 2 12 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 1

130 40 2 2 1 4 3 10 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 1 1 2 2

131 31 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

132 32 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

133 33 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

134 34 2 1 1 4 3 2 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

135 35 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

136 36 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

137 37 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

138 38 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

MASTER CHART

139 39 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

140 40 2 1 1 4 3 5 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 2 2 2 1 2 2

141 31 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 1 2 2

142 32 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 1 2 2

143 33 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

144 34 2 1 1 4 3 6 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

145 35 2 1 1 4 3 6 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

146 36 2 1 1 4 3 5 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

147 37 2 1 1 4 3 5 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

148 38 2 1 1 4 3 5 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

149 39 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

150 40 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

151 41 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

152 42 2 1 1 4 3 2 2 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

153 43 2 1 1 4 3 3 1 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

154 44 2 1 1 4 3 3 3 5 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

155 45 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

156 46 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

157 47 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

158 48 2 1 1 4 3 4 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

159 49 2 1 1 4 3 3 3 1 2 2 2 2 13 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

160 50 2 1 1 4 3 5 3 1 2 2 2 2 14 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

161 41 2 1 1 4 4 6 3 1 2 2 2 2 14 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

162 42 2 1 1 4 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

163 43 2 1 1 4 4 5 3 1 2 2 2 2 14 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

164 44 2 1 1 4 4 2 3 1 2 2 2 2 14 1 2 2 2 2 1 3 3 3 2 3 2 2 2 2 2

165 45 2 2 1 4 4 5 3 4 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

166 46 2 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

167 47 2 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

168 48 2 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

169 49 2 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

170 50 2 2 1 5 4 5 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

171 41 2 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

172 42 2 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

173 43 2 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

174 44 2 1 1 5 4 2 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

175 45 3 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

MASTER CHART

176 46 3 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

177 47 3 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

178 48 3 2 1 5 4 5 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

179 49 3 1 1 5 4 5 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

180 50 3 1 1 5 4 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

181 41 3 2 1 5 4 7 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

182 42 3 1 1 5 4 3 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

183 43 3 2 1 5 4 6 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

184 44 3 2 1 5 5 6 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

185 45 3 2 1 5 5 5 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

186 46 3 1 1 5 5 5 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

187 47 3 1 1 5 5 2 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

188 48 3 1 1 5 5 4 3 1 2 2 2 2 14 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

189 49 3 1 1 5 5 3 3 1 2 2 2 2 15 1 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

190 50 3 1 1 5 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

191 41 3 1 1 5 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

192 42 3 2 1 5 5 5 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

193 43 3 2 1 5 5 5 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

194 44 3 2 1 5 5 6 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

195 45 3 2 1 5 5 7 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

196 46 3 1 1 5 5 3 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

197 47 3 1 1 5 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

198 48 3 1 1 5 5 3 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

199 61 3 1 1 5 5 3 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

200 62 3 2 1 5 5 5 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

201 63 3 2 1 6 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

202 64 3 2 1 6 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

203 65 3 1 1 6 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

204 66 3 1 1 6 5 5 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

205 67 3 1 3 6 5 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

206 68 3 2 3 6 6 5 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

207 69 3 1 3 6 6 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

208 70 3 1 3 6 6 4 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

209 71 3 2 3 6 6 6 3 1 2 2 2 2 15 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

210 72 3 2 3 6 6 6 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

211 73 3 2 3 6 6 5 3 4 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

212 74 3 2 3 6 6 5 3 4 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

MASTER CHART

213 75 3 2 3 6 6 5 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

214 76 3 1 3 6 6 3 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

215 77 3 2 3 6 6 5 3 4 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

216 78 3 1 3 6 6 4 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

217 79 3 2 3 6 6 6 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

218 80 3 1 3 6 7 4 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

219 81 3 1 3 6 7 4 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 2 2 1 2 2

220 82 3 1 3 6 7 5 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 1 2 1 1 2

221 83 3 1 3 6 7 3 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 1 1 1 1 2

222 84 3 1 3 6 7 3 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 1 1 1 1 2

223 85 3 1 3 6 7 5 3 1 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 1 1 1 1 2

224 86 3 2 3 6 7 4 3 4 2 2 2 2 16 1 2 2 2 2 2 4 4 4 2 4 1 1 1 1 2

225 87 3 1 3 6 7 4 3 1 2 2 2 2 16 1 2 2 1 1 2 1 1 1 1 4 1 1 1 1 2

226 88 3 2 3 6 7 5 3 1 2 1 2 2 16 1 2 1 2 2 2 1 1 1 1 4 1 1 1 1 2

227 89 3 2 3 6 7 4 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 2

228 61 3 2 3 6 7 5 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 2

229 62 3 2 3 6 7 5 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 2

230 63 3 2 3 6 7 2 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 1

231 64 3 2 3 6 7 2 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 1

232 65 3 2 3 6 7 2 3 1 2 1 2 2 16 1 2 1 1 1 2 1 1 1 1 4 1 1 1 1 1

233 66 1 2 1 1 1 4 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1

234 67 1 2 1 1 1 4 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1

235 68 1 2 1 1 1 5 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

236 69 1 2 1 1 1 9 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

237 70 1 2 1 1 1 4 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

238 71 1 2 1 1 1 4 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

239 72 1 2 1 1 1 4 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

240 73 1 2 1 1 1 5 3 1 2 1 1 1 16 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

241 74 1 2 1 1 1 1 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

242 75 1 2 1 1 1 1 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

243 53 1 2 1 1 1 2 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

244 54 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

245 55 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

246 56 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

247 57 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

248 58 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1

249 59 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

MASTER CHART

250 60 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

251 51 1 2 1 1 1 2 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

252 52 1 2 1 1 1 3 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

253 53 1 2 1 1 1 6 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

254 54 1 2 1 1 1 5 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

255 55 1 2 1 1 1 9 3 1 2 1 1 1 17 1 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

256 56 1 2 1 1 1 4 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

257 71 1 2 1 1 1 3 3 1 2 1 1 1 17 1 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

258 71 1 2 1 1 1 2 3 1 2 1 1 1 17 1 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

259 71 1 2 1 1 1 2 3 1 2 1 1 1 17 2 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

260 71 1 2 1 1 1 4 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

261 81 1 2 1 1 1 6 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

262 81 1 2 1 2 1 5 3 1 2 1 1 1 17 2 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

263 81 1 2 1 2 1 6 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

264 62 1 2 1 2 1 3 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

265 62 1 2 1 2 1 4 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

266 62 1 2 1 2 1 7 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

267 62 1 2 1 2 1 5 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

268 62 1 2 1 2 1 4 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

269 62 1 2 1 2 1 4 3 1 2 1 1 1 17 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

270 61 1 2 1 2 1 5 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

271 61 1 2 1 2 1 5 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

272 61 1 2 1 2 1 6 3 1 2 1 1 1 18 2 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

273 61 1 2 1 2 1 6 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

274 61 1 2 1 2 1 3 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

275 61 1 2 1 2 2 3 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

276 51 1 2 1 2 2 9 3 1 2 1 1 1 18 2 1 2 2 2 2 1 1 1 2 1 1 1 1 1 1

277 25 1 2 1 2 2 3 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

278 25 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

279 25 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 1 1 2 1 1 1 2 1 1 1 1 1 1

280 25 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 1 1 2 2 2 2 2 1 1 1 1 1 1

281 25 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 1 1 2 2 2 2 2 1 1 1 1 1 1

282 25 1 2 1 2 2 3 3 1 2 1 1 1 18 2 1 2 1 1 2 2 2 2 2 1 1 1 1 1 1

283 25 1 2 1 2 2 5 3 1 2 1 1 1 18 2 1 2 1 1 2 2 2 2 2 1 1 1 1 1 1

284 24 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 1 1 2 2 2 2 2 1 1 1 1 1 1

285 24 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

286 24 1 2 1 2 2 4 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

MASTER CHART

287 24 1 2 1 2 2 6 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

288 24 1 2 1 2 2 2 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

289 24 1 2 1 3 2 8 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

290 23 1 2 1 3 2 5 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

291 23 1 2 1 3 2 7 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

292 23 1 2 1 3 2 7 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

293 23 1 2 1 3 2 7 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1

294 23 1 2 1 3 2 6 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

295 23 1 2 1 3 2 3 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

296 22 1 2 1 3 2 8 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

297 22 1 2 1 3 2 8 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

298 22 1 2 1 3 2 3 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

299 22 1 2 1 3 2 4 3 1 2 1 1 1 18 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

300 22 1 2 1 3 2 3 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 1 2 1 1 1 1

301 22 1 2 1 3 2 3 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

302 21 1 2 1 3 2 5 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

303 21 1 2 1 3 2 2 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

304 21 1 2 1 3 2 4 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

305 21 1 2 1 3 2 2 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

306 21 1 2 1 3 2 4 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

307 20 1 2 1 3 2 4 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

308 20 1 2 1 3 2 5 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

309 20 1 2 1 3 2 6 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

310 20 1 2 1 3 2 6 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

311 20 1 2 1 3 2 1 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

312 19 1 2 1 3 3 6 3 1 2 1 1 1 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

313 19 1 2 1 3 3 4 3 1 2 1 1 2 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

314 19 1 2 1 3 3 6 3 1 2 1 1 2 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

315 19 1 2 1 3 3 5 3 1 2 1 1 2 19 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

316 19 1 2 1 3 3 4 3 1 2 2 1 2 13 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

317 19 1 2 1 3 3 6 3 1 2 2 1 2 13 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

318 18 1 2 1 3 3 8 3 1 2 2 1 2 13 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

319 18 1 2 1 3 3 6 3 1 2 2 1 2 13 2 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1

320 18 1 2 1 4 3 4 3 1 2 2 1 2 13 2 1 2 2 2 2 2 2 2 2 2 2 1 2 1 1

321 18 1 2 1 4 3 4 3 1 2 2 2 2 13 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

322 18 1 2 1 4 3 4 3 1 2 2 2 2 13 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

323 18 1 2 1 4 3 5 3 1 2 2 2 2 13 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

MASTER CHART

324 38 1 2 1 4 3 4 3 1 2 2 2 2 13 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

325 38 1 2 1 4 3 4 3 1 2 2 2 2 13 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

326 38 1 2 1 4 3 6 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

327 38 2 2 1 4 3 4 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

328 38 2 2 1 4 3 5 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

329 37 2 2 1 4 3 4 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

330 37 2 2 1 4 3 4 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

331 37 2 2 1 4 3 4 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

332 37 2 2 1 4 3 4 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

333 37 2 2 1 4 3 5 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

334 36 2 2 1 4 3 2 3 1 2 2 2 2 14 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

335 36 2 2 1 4 3 4 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 1 1

336 36 2 2 1 4 3 2 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 1 1

337 36 2 2 1 4 3 3 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 1 1

338 36 2 2 1 4 3 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 1 1

339 36 2 2 1 4 3 4 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 1 1

340 35 2 2 1 4 3 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

341 35 2 2 1 4 3 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

342 35 2 2 1 4 3 5 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

343 35 2 2 1 4 3 4 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

344 35 2 2 1 4 3 4 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

345 34 2 2 1 4 3 5 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

346 34 2 2 1 4 3 7 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

347 34 2 2 1 4 3 2 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

348 34 2 2 1 4 3 2 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

349 34 2 2 2 4 3 2 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 1

350 34 2 2 2 4 3 1 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 2 2 1 2 2 2

351 33 2 2 2 4 3 3 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

352 33 2 2 2 4 3 5 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

353 33 2 2 2 4 3 4 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

354 33 2 2 2 4 3 4 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

355 33 2 2 2 4 3 3 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

356 33 2 2 2 4 3 3 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

357 32 2 2 2 4 3 2 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

358 32 2 2 2 4 3 3 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

359 32 2 2 2 4 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

360 32 2 2 2 4 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

MASTER CHART

361 32 2 2 2 4 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

362 32 2 2 2 4 4 3 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

363 31 2 2 2 4 4 3 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

364 31 2 2 2 4 4 3 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

365 31 2 2 2 4 4 7 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

366 31 2 2 2 4 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

367 31 2 2 2 4 4 5 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

368 31 2 2 2 4 4 3 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

369 31 2 2 2 4 4 3 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

370 30 2 2 2 4 4 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 1 2 2 2

371 30 2 2 2 4 4 2 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

372 30 2 2 2 4 4 1 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

373 30 2 2 2 4 4 5 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

374 30 2 2 2 4 4 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

375 30 2 2 2 4 4 4 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

376 29 2 2 2 4 4 3 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

377 29 2 2 2 4 4 1 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

378 29 2 2 2 4 4 2 3 1 2 2 2 2 15 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

379 29 2 2 2 4 4 2 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

380 29 2 2 2 4 4 5 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

381 29 2 2 2 4 4 5 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

382 28 2 2 2 4 4 2 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

383 28 2 2 2 4 4 3 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

384 28 2 2 2 4 4 2 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

385 28 2 2 2 4 4 2 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

386 28 2 2 2 4 4 1 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

387 28 2 2 2 4 4 4 3 1 2 2 2 2 16 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

388 28 2 2 2 4 4 2 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

389 27 2 2 2 4 4 4 3 1 2 2 2 2 13 2 2 2 2 2 2 3 3 3 2 3 2 2 2 2 2

390 27 2 2 2 4 4 4 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 3 2 2 2 2 2

391 27 2 2 2 5 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 3 2 2 2 2 2

392 27 2 2 2 5 4 6 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

393 27 2 2 2 5 4 6 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

394 27 2 2 2 5 4 4 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

395 26 2 2 2 5 4 6 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

396 26 2 2 2 5 4 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

397 26 2 2 2 5 4 4 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

MASTER CHART

398 26 2 2 2 5 4 1 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

399 26 2 2 2 5 4 4 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

400 26 2 2 2 5 4 5 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

401 26 3 2 2 5 4 6 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

402 25 3 2 2 5 4 3 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

403 25 3 2 2 5 4 10 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

404 25 3 2 2 5 4 4 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

405 25 3 2 2 5 4 4 3 1 2 2 2 2 15 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

406 25 3 2 2 5 4 4 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

407 25 3 2 2 5 4 6 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

408 25 3 2 2 5 4 2 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

409 25 3 2 2 5 4 5 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

410 24 3 2 2 5 4 4 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

411 24 3 2 2 5 4 4 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

412 24 3 2 2 5 4 4 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

413 24 3 2 2 5 4 4 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

414 24 3 2 2 5 4 2 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

415 24 3 2 2 5 4 7 3 1 2 2 2 2 16 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

416 24 3 2 2 5 4 3 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

417 23 3 2 2 5 4 1 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

418 23 3 2 2 5 4 2 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

419 23 3 2 2 5 5 6 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

420 23 3 2 2 5 5 5 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

421 23 3 2 2 5 5 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

422 23 3 2 2 5 5 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

423 23 3 2 2 5 5 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

424 22 3 2 2 5 5 5 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

425 22 3 2 2 5 5 4 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

426 22 3 2 2 5 5 2 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

427 22 3 2 2 5 5 5 3 1 2 2 2 2 14 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

428 22 3 2 2 5 5 6 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

429 22 3 2 2 5 5 5 3 1 2 2 2 2 13 2 2 2 2 2 2 4 4 4 2 4 2 2 2 2 2

430 22 3 2 2 5 5 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

431 21 3 2 2 5 5 5 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

432 21 3 2 2 5 5 4 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

433 21 3 2 2 5 5 4 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

434 21 3 2 2 6 5 6 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

MASTER CHART

435 21 3 2 2 6 5 2 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

436 21 3 2 2 6 5 4 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

437 21 3 2 2 6 5 2 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

438 21 3 2 3 6 5 4 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

439 21 3 2 3 6 5 6 3 1 2 2 2 2 15 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

440 20 3 2 3 6 6 3 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

441 20 3 2 3 6 6 5 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

442 20 3 2 3 6 6 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

443 20 3 2 3 6 6 5 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

444 20 3 2 3 6 6 1 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

445 20 3 2 3 6 6 2 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

446 20 3 2 3 6 6 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

447 19 3 2 3 6 6 3 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

448 19 3 2 3 6 6 6 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

449 19 3 2 3 6 6 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

450 19 3 2 3 6 7 5 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

451 19 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

452 19 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

453 19 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

454 19 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

455 19 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

456 18 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

457 18 3 2 3 6 7 4 3 1 2 2 2 2 16 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

458 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

459 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

460 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

461 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

462 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

463 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2

464 18 3 2 3 6 7 4 3 1 2 2 2 2 13 2 2 2 2 2 1 4 4 4 2 4 2 2 2 2 2