Book Description

Unhealthy alcohol use is a common, undertreated, and growing public health problem among U.S. adults. Community-level factors, such as stressors within neighborhoods and workplaces, in addition to elements within the health care system such as the quality of primary care, may influence the prevalence of unhealthy alcohol use as well as receipt of evidence-based treatment. This dissertation describes associations between neighborhood disadvantage and patterns of unhealthy alcohol use (Chapter 2), examines relationships between job-related stressors and unhealthy alcohol use (Chapter 3), and explores whether patient-centered medical home (PCMH) implementation was related to receipt of evidence-based care among people with unhealthy alcohol use (Chapter 4). Chapters 2 and 4 examine these relationships using electronic health record (EHR) data from the Veteran Health Administration outpatients, while Chapter 3 uses a national sample of working adults from the National Health Interview Survey. Overall, findings suggest that unhealthy alcohol use and alcohol-related conditions are more prevalent among VA patients living in disadvantaged areas (Chapter 2). Specifically, we found that neighborhood disadvantage was positively associated with all patterns of unhealthy alcohol use and alcohol-related harm. Findings also suggested consistent moderation by race/ethnicity and urbanicity. Association sizes were largest for people of Black/African American and American Indian/Alaska Native race/ethnicities and for those residing in more urban neighborhoods. Among VA patients with unhealthy alcohol use, those served by primary care clinics with stronger PCMH implementation had higher probabilities of brief intervention and medications for alcohol use disorders. These findings indicate that – likely due to increased patient-centeredness of care – PCMH implementation may encourage evidence-based care for unhealthy alcohol use (Chapter 4). Yet, descriptive findings suggested that clinics serving more disadvantaged VA patients tend to have lower PCMH rankings. Finally, relationships between job stress and unhealthy alcohol use require additional investigation (Chapter 3). We found few statistically significant relationships between job-related stressors (job insecurity, financial stress, and job strain) and three patterns of unhealthy alcohol use in gender-stratified models. For females, while financial stress was positively associated with heavy episodic drinking on heavy drinking days, job strain was negatively associated with drinking above recommended limits. Overall, findings from these analyses highlight the need to expand preventive strategies and high-quality primary care for those living in structurally disadvantaged communities.