14 Chapter 14: Behavioral Health Epidemiology

Chapter 14: Behavioral Health Epidemiology

Objectives

After completing this module, you should be able to:

Describe the field of behavioral health.

Describe the methods of measurement in behavioral health epidemiology.

14.1 Introduction

Despite the title of this book, there is no singular definition of behavioral health. The American Medical Association states, “Behavioral health generally refers to mental health and substance use disorders, life stressors and crises and stress-related physical symptoms” (American Medical Association, 2022). Another source states that behavioral health includes mental health, substance use, and health behaviors (Alvernia University, 2021). In this book, behavioral health is defined as a broad field that includes mental health, alcohol and substance use disorders, health behaviors, and the determinants and consequences of these issues.

As behavioral health is a broad field that encompasses a large variety of topics, behavioral health epidemiology (the study of the distribution of behavioral health outcomes and their determinants) is equally broad. In that regard, insights and hypotheses regarding the determinants of an outcome are gained from describing the person, place, and time at which the outcome occurs (i.e., descriptive epidemiology). Thus, the primary focus of this chapter will be on descriptive epidemiological studies of behavioral health outcomes, primarily alcohol and substance use.

14.2 Examples of Research in Descriptive Behavioral Health Epidemiology

To provide examples of research in behavioral health epidemiology, the author summarizes two of their own published works in descriptive epidemiology of behavioral health outcomes, primarily cannabis and alcohol use (as the first author or the corresponding author).

14.2.1 Example 1: Nationally representative survey on the use of cannabis among adult community residents in Thailand after de facto legalization

Introduction: Thailand is an upper-middle-income country in Southeast Asia that once highly criminalized the use of narcotics, including soft drugs such as cannabis. Following the global movement to decriminalize cannabis, which began in the 2010s, the Thai government issued a ministerial notification that removed cannabis from the list of narcotics in 2022. There were very few regulations for cannabis use and distribution; thus, the decriminalization process functioned akin to legalization. Although the main rhetoric pertaining to decriminalization was to ease access to medical cannabis (Royal Thai Government, 2022), stakeholders raised concerns that the decriminalization would lead to recreational substance use and misuse (Thai Rath, 2022), particularly among men and young people (Chen et al., 2018; Dunbar et al., 2022; Harris-Lane et al., 2023; Struble et al., 2023).

Despite these ongoing changes, there had been no survey to examine cannabis use behaviors among the general population of Thailand. Such findings could yield useful information for stakeholders and health decision-makers. Thus, the investigators conducted the study to investigate cannabis use behaviors and cannabis-related harms and harmful behaviors, stratified by age group and sex (Jayuphan et al., 2024).

Methods: The investigators contracted a survey research firm to conduct a nationally representative survey among community members aged 20 years or older in Thailand in May 2023. The study instrument was a structured questionnaire in Thai with four sections: 1. Demographic and socioeconomic characteristics; 2. Patterns of cannabis use; 3. Access to cannabis and exposure to cannabis; and 4. Other health behaviors. Investigators sampled the study areas using stratified multi-stage sampling, then contacted local primary healthcare facilities and requested community health volunteers to help introduce the survey enumerators to the potential study participants. The enumerators provided information about the study to the potential participants, answered relevant questions, and asked for consent to participate. The institutional review board allowed the use of verbal informed consent instead of written informed consent. Data were collected by self-administered questionnaires or face-to-face interviews, depending on the individual’s literacy level. Investigators analyzed data using descriptive statistics with sampling weight adjustment.

Results: Investigators found that young people were more likely to use cannabis recreationally than working-age adults and elderly people, and that men were more likely to use cannabis recreationally than women (Table 14.2.1.1).

 

Table 14.2.1.1 Cannabis use status and purpose among the study participants, disaggregated by sex assigned at birth and age groups with weighted column percentages

Characteristic	Youth, Male	Youth, Female	Working Age, Male	Working Age, Female	Elderly, Male	Elderly, Female	P-value*
	(n = 102)	(n = 81)	(n = 755)	(n = 819)	(n = 181)	(n = 253)
Cannabis Use Status	(n = 99)	(n = 81)	(n = 752)	(n = 819)	(n = 181)	(n = 253)
Never users	59%	77%	62%	79%	59%	78%	<0.001
Former users (not in past 12 months)	20%	15%	19%	9%	27%	12%
Current users (in past 12 months	21%	9%	19%	13%	14%	10%
Main purpose of cannabis use (among former and current users only)	(n = 43)	(n = 19)	(n = 288)	(n = 172)	(n = 74)	(n = 55)
Recreation	91%	79%	70%	45%	55%	22%	<0.001
Other non-medical purposes	9%	16%	27%	47%	34%	58%
Medical purpose	0%	5%	3%	8%	11%	20%

Adapted from Jayuphan et al., 2024

Discussion: The authors made the following remarks regarding the variations in cannabis use and purpose of use by age and sex, including a comparison of the study findings with previous studies in Thailand and elsewhere. The investigators also remarked on the potential for Thailand’s war on drugs in the early 2000s (Angkurawaranon et al., 2018) to have introduced social desirability bias to the findings of studies during that period.

“Approximately 30 percent of the participants in this study had used cannabis in their lifetime, half of whom had stopped using before the de facto legalization. This contrasted sharply with the survey findings during the 2000s and 2010s, where self-reported cannabis use prevalence was below 1 percent²². This study’s findings suggested that social desirability might have heavily influenced the findings of previous studies, and that cannabis use was more common than reported: particularly in the 2000s. In this current survey, male participants were more likely to report recreation as the main purpose of cannabis use than female participants in the same age group. Working-aged and elderly female participants were more likely to report using cannabis for other non-medical purposes than the other groups. Recreational use of cannabis is known to be a negative coping mechanism against stress^23–25; however, it can also be social and not stress-related26. In this study, the “other purposes” category was meant to be inclusive and non-specific; thus, caveats are required with regard to this non-specificity…”

Quoted from Jayuphan et al., 2024, Discussion section

14.2.2 Example 2: Nationally representative surveys among adults in Thailand on drinking behavior during the first five months of the COVID-19 pandemic

Introduction: Alcohol consumption in Thailand generally takes place during social gatherings and events (Wichaidit et al., 2019). As such, during the first year of the COVID-19 pandemic, when vaccines were unavailable, the Thai government utilized various restrictions, including stricter alcohol controls to limit socialization. Timely empirical data regarding drinking in the general population of Thailand can be useful for policymakers to make informed decisions regarding alcohol control. Thus, the investigators described self-reported drinking behavior among the Thai population (15 years old and over) during the first five months of the COVID-19 state of emergency (Wichaidit et al., 2021).

Methods: Investigators analyzed data from four rounds of nationally representative, phone-based surveys conducted by a Bangkok-based survey research firm. The investigators pooled data from the previous surveys and presented descriptive statistics regarding alcohol consumption within the past 30 days (or from the beginning of the month) during each round of the surveys with p-for-trend.

Results: The investigators reported the prevalence of alcohol consumption within the past 30 days or the beginning of the month of the survey during each of the four rounds (waves) of the survey — part of which is shown in Table 14.2.2.1

Table 14.2.2.1 Prevalence of recent alcohol consumption within the past 30 days (Waves 1, 3, 4) or since the beginning of the month (Wave 2) by sex of the respondent (weighted percentage)

Outcome	Wave 1 (mid-Apr 2020)	Wave 2 (mid-May 2020)	Wave 3 (mid-June 2020)	Wave 4 (late July 2020)	P-for-trend
	(n = 637)	(n = 600)	(n = 606)	(n = 602)
Sex of the participant
Male	44%	44%	30%	37%	<0.001
Female	57%	54%	51%	40%	0.002

Current drinkers only. Never and former drinkers excluded. Bold numbers denote statistical significance at a 95% level of confidence.

Adapted from Wichaidit et al., 2021

Discussion: There was a clear drop in the prevalence of recent alcohol consumption during Wave 3 (mid-May 2020) at a time when restrictions were starting to ease. The investigators noted this insight in the manuscript’s Discussion section, which also included several remarks regarding potential sources of information bias.

“During the pre-pandemic period, alcohol consumption in the Thai population appeared to be for social purpose rather than as a negative coping mechanism against stress (Wichaidit et al., 2019). This pattern appeared to be unchanged during the survey periods. Several caveats are advised in the interpretation of these findings. The wording of the question was unique to each survey, and the time frame for the question on recent alcohol consumption during Wave 2 was from the 1st of May until the date of data collection, not within the past 30 days like in other studies. However, such distinction might have contributed to the clarify of the data. The lifting of the ban on alcohol sale was on May 3rd, thus only two days in May were subjected to the ban. Furthermore, the answer choices of “Drank less [frequently]”, “Drank just the same” and “Drank more frequently” was based solely on the respondent’s own perception of what was their “usual” frequency. Drinking more frequently than usual during a public health crisis might be perceived as a socially undesirable behavior, thus social desirability also could have influenced the study findings…”

Adapted from Wichaidit et al., 2021, Discussion section

14.3 Methods of Measurement in Behavioral Health Epidemiology

In order for descriptive behavioral health epidemiology findings to be relevant and useful for stakeholders, the findings must become available in a timely manner. Launching surveys in a timely manner requires creating an inventory of measurement questions for study instruments in advance based on previously used questionnaires for surveys examining behavioral health in the general population (Paileeklee et al., 2016; Wichaidit et al., 2021). For emerging issues, such as cannabis use, the development of an inventory of measurement questions can be based on the adaptation of existing instruments, such as the DFAQ-CU, combined with adapting measurement questions used for similar outcomes (Assanangkornchai et al., 2022; Cuttler & Spradlin, 2017). For example, questions regarding cannabis use status may be adapted from nationally representative survey questions regarding alcohol and tobacco use.

The author has translated the measurement questions for cannabis use status and alcohol consumption during the COVID-19 pandemic into English (see Box 14.3.1).

Box 14.3.1 Translated measurement questions about behavioral health issues, specifically cannabis use and alcohol consumption, in nationally representative surveys in Thailand

Questions regarding cannabis use As shown in Example 1 (Jayuphan et al., 2024): B1_1. In this lifetime, have you ever used cannabis? [ ] 0. Never (skip to B2_1) [ ] 1. Yes [ ] 99. Refuse to answer (skip to B2_1) B1_4. The main purpose for your cannabis use during this lifetime most closely aligns with which of the following reasons? (Select only one answer.) [ ] 1. Recreation (for enjoyment/relaxation, socializing) [ ] 2. Medical/treatment purposes [ ] 3. As a sleep aid [ ] 4. To increase appetite [ ] 5. Other (specify) [ ] 99. Refuse to answer B1_5. When was the last time you used cannabis? [ ] 1. More than 1 year ago [ ] 2. 9–12 months ago [ ] 3. 6–8 months ago [ ] 4. 3–5 months ago [ ] 5. 1–2 months ago [ ] 6. Within the past month but not within the past 2 weeks [ ] 7. Within the past 2 weeks but not within the past week [ ] 8. Within the past week but not since yesterday [ ] 9. Yesterday [ ] 10. Today [ ] 11. I’m high (“floating”) right now [ ] 88. Don’t know / not sure / don’t remember [ ] 99. Refuse to answer Questions regarding alcohol use during the COVID-19 pandemic As shown in Example 2 (Wichaidit et al., 2021). Please note that the version shown in this box is simplified and does not contain the same level of detail as the survey questionnaire: From Wave 1 Q3. In the past 12 months, have you had any alcohol? [ ] 1. No (Skip to Question 5) [ ] 2. Yes Q4. Only among those who had alcohol in the past 12 months: Have you had any alcohol in the past 30 days? [ ] 1. Did not drink at all [ ] 2. Drank less than usual [ ] 3. Drank the same amount as usual [ ] 4. Drank more than usual From Wave 2 Q1. In the past 12 months, have you had any alcohol? [ ] 1. No (Skip to Question 4) [ ] 2. Yes Q3. Since the 1st of May, have you had any alcohol? [ ] 1. Did not drink at all [ ] 2. Drank less than usual [ ] 3. Drank the same amount as usual [ ] 4. Drank more than usual From Wave 3 Q1. In the past 12 months, have you had any alcohol? [ ] 1. No (Skip to Question 5) [ ] 2. Yes Q4. In the past 30 days, have you had any alcohol? If yes, compared to normal times, have you been drinking less than usual or more than usual? [ ] 1. Did not drink at all [ ] 2. Drank less than usual [ ] 3. Drank the same amount as usual [ ] 4. Drank more than usual From Wave 4 Q1. In the past 12 months, have you had any alcohol? [ ] 1. No (Skip to Question 5) [ ] 2. Yes Q4. In the past 30 days, have you had any alcohol? If yes, compared to your normal consumption, have you been drinking less than usual or more than usual? [ ] 1. Did not drink at all [ ] 2. Drink less than usual [ ] 3. Drink the same amount as usual [ ] 4. Drink more than usual

Although the responses to these questions can provide initial insights regarding changes in alcohol consumption during the COVID-19 pandemic, a number of issues with the measurement questions can be observed. Firstly, there were no questions on the exact extent to which the change happened. Additional questions to measure standard drinks within 30 days at pre-pandemic vs. the study period could yield additional insights. Secondly, the frequency of consumption was not measured, and it is unknown whether those who drank the same amount as usual in the past 30 days actually reduced the frequency of consumption but increased the amount of alcohol per intake, i.e., engaging in binge-drinking. These remarks could inform stakeholders in alcohol control who wishes to engage in additional studies.

 

14.4 Conclusion

Behavioral health refers to a broad field that includes mental health, alcohol and substance use disorders, health behaviors, and the determinants and consequences of these issues. Behavioral health epidemiology refers to an equally broad field: the distribution of behavioral health outcomes and their determinants. In this chapter, the author provided examples of research in descriptive behavioral health epidemiology and shared examples of measurement questions used in these studies. Readers who are interested in pursuing descriptive behavioral health epidemiology are advised to develop their own inventory of measurement questions in order to rapidly obtain insights in time-sensitive contexts.

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