Kava: A longitudinal study into kava consumption and emerging

Kava: A longitudinal study into kava consumption and
emerging patterns of kava usage with subsequent effects on
Pacific families living in South Auckland
Hilda Port
A dissertation submitted to Auckland University of Technology
in partial fulfilment of the requirements for the degree of
Bachelor of Health Science (Honours) (Psychology)
2014
Department of Psychology
Primary Supervisor: Steve Taylor
I Table of Contents
List of Figures …..……………………………………………………...iv
List of Tables.……...………………………………………………….....v
Attestation of authorship………….…………………………………...vi
Acknowledgements …………………...……………………………….vii
Abstract …………………………………...…………………………..viii
Chapter1: Introduction……………………………….………………...1
1.1 Kava and culture ………………………………………..…….2
1.2 Biochemistry ……………………………………..…………...3
1.2.1 Kava and its chemical makeup…………………….....4
1.3 Kava extraction process………………………..……………...5
1.4 Kava classification…………………………………..………...6
1.5 Kava versus alcohol ………………………………………..…7
1.6 Beneficial effects of kava ……………………………………..8
1.7 Adverse effects of kava ……………………………………….9
1.7.1 Case Study…………….…………………………….10
1.7.2 Kava dermopathy.…………………………………...11
1.7.3 Hepatoxicity ………………………………………...12
1.7.4 Kava dependency …………………………………...13
1.7.5 Kava and mental health……………………………...14
1.7.6 Psychosocial aspects of kava………………………..15
1.8 Aim of research ……………………………………………...16
Chapter 2: Methods …………………………….………….…………18
2.1 Pacific Islands Families study ….……………………………19
2.2 Participants ……………………….……………………….…20
2.3 Measures ………………………….…………………………21
2.4 Data analysis …………..…………………………………….22
Chapter 3: Results ………………………..…………………………...23
3.1 Cohort sample …………………………………..…………...24
3.2 Outcomes – Descriptive statistics ………………………..….25
3.3 Main analysis of associations ……………………………..…26
II Chapter 4: Discussions ………………………..………………………27
4.1 Summary of main results………………………………….…28
4.2 Interpretations of results …………………………………..…29
4.3 Conclusions …………………………………….…………....30
References
Appendix
A: Kava Questions ...………………………………..…………...31
B: GEQ modified questions PIACCULT and NZACCULT…….32
C: GHQ-12………………………………………………...…….33
III List of Figures
Figure
Page
1
Kava and culture: Kava ceremony
1
2
Kava from plant to drink: The process of making kava
4
3
Kavalactones: Chemical structure of six kavalactones
5
4
Dried Rootstock Composition: The components of kava
rootstock
7
5
Kava Dermopathy: Scale-like skin on heavy kava users
13
6
Ethnicity and Kava Usage bar graph
27
IV List of Tables
Table
Page
1
Ethnicity
22
2
Age
23
3
Acculturation
23
4
Psychological Distress
24
5
Is Kava User (KU)
24
6
How often kava is consumed
25
7
Number of drinks consumed in a kava session
25
8
Who kava is consumed mostly with
26
9
Ethnicity and kava usage
27
10
Age and kava usage
28
11
Psychological distress and kava usage
29
12
Acculturation and kava usage
29
13
Alcohol and kava usage
30
14
Suggest KU cut down
30
15
Problematic kava usage and ethnicity
31
16
Problematic kava usage and age
32
17
Problematic kava usage and psychological distress
33
18
Problematic kava usage and acculturation
33
V Attestation of Authorship
I hereby declare that this submission is my own work and that, to the best
of my knowledge and belief, it contains no material previously published
or written by another person (except where explicitly defined in the
acknowledgements), nor material which to a substantial extent has been
submitted for the award of any other degree or diploma of a university or
other institution of higher learning.
Signed ___________________________________ Date _____________
VI Acknowledgements
First and foremost I would like to thank the Ministry of Health for
providing me with a scholarship to complete my BHSc Honours
(Psychology) and also AUT for their financial assistance fund which took
a lot of financial pressure off me so I could focus on my studies.
A big thank you to Professor Janis Patterson and her dedicated team of
researchers who have diligently collected data in the Pacific Islands
Families study that has enabled me to gather longitudinal research data on
a topic that is of great interest to me.
I cannot thank my supervisor Steve Taylor enough for his support;
encouragement, and belief in my ability to conduct, complete, and present
this dissertation. I have appreciated the ongoing guidance, insight, and
patience he has given. Malo aupito!
Last but not least I want to thank my family and friends for their love and
support. Words cannot express the gratitude I have for my children who,
have sacrificed spending time with me, home cooked meals, money, and
a clean house to say the least. You are all such a blessing and I thank you
for your patience, love, and understanding. Ofa lahi atu.
VII Abstract
Kava is a traditional beverage that has been a significant part of Pacific Island culture
for centuries. Many Pacific people understand and utilise the unique properties of
kava for use in traditional healing (Lindstrom, 2009; Smith, 2011). With kava going
global in the late 1990’s, Western cultures have embraced its therapeutic qualities and
developed pharmaceutical forms of Kava through extracting kava lactones from the
kava plant. In the drug form and utilised as a natural medicine, kava has shown to be
beneficial in the treatment of stress related disorders including anxiety, insomnia, and
panic disorder (Copley, Cave, Ellis, & Middleton, 2002). Since the development of
kava as an alternative medicine, links have been made to liver dysfunction and other
adverse effects. For Pacific people who consume kava in an aqueous state, there is
little evidence to suggest that there are any harmful long-term effects despite the large
amounts being consumed over a long period of time (Rasmussen, 2005; Food
Standards Australia New Zealand, 2004). Physiological affects are known to dissipate
upon decrease or cessation of kava consumption however, there is some evidence to
suggest that kava has negative psychosocial effects on kava users and subsequently
their families (Kava, 2001; Nosa & Ofanoa, 2009).
Aim: the aim of this study was to access specific kava data from the longitudinal
Pacific Islands Families (PIF) study and establish if there were any emerging patterns
in relation to kava consumption. The PIF study follows a birth cohort of Pacific Island
families living in South Auckland. Kava questions were included in the questionnaire
when the data was collected in Year 1 and Year 11.
Method: Kava specific data was extracted from the PIF study and participant
information selected to include only Pacific adult males in the sample. Statistical
analysis was conducted to explore frequencies and investigate bivariate associations
with kava usage.
Results: Patterns have emerged showing increases in kava consumption across all
Pacific cultures with the largest increases among the Tongan participants. Kava
consumption is increasing across the lifespan as the Pacific population ages, so does
the increase in Kava consumption across all age groups. Kava usage was associated
with acculturation into New Zealand society. Holding onto one’s culture may be
difficult due to immigration, adapting to new societal values, whilst dealing with
VIII feelings surrounding leaving a culture behind. Kava ceremonies foster an environment
that enhances one’s relationship with their inherent culture. With the increase in Kava
consumption also brings an increase in psychosocial problems associated with Kava
Usage. These include acculturation difficulties, and the increase in frequency of Kava
consumption. Of the participants who acknowledged significant others had raised
concerns over their Kava Usage, 80% identified as Tongan. For Pacific people, there
are limited physiological effects that may cause some form of physiological
dysfunction. Notwithstanding the psychological impact that may interfere with
interpersonal relationships. With the substantial growth of kava consumption it is
beneficial for the wider community if further research is conducted and development
of a kava usage inventory be explored.
IX CHAPTER 1: INTRODUCTION
In Japan the Japanese drink Sake, the Russians are renown for their Vodka, for the
Irish its Guinness, the French and Champagne, and the Pacific Island nations have
kava. All beverages are steeped in history and connected to a particular region. All
have a tradition that is unique to their culture. The purpose of this study is to take a
closer look at the consumption and practices surrounding kava with the intention of
identify emerging patterns of kava consumption and the effects this may have on
families. Through the present study accessing data from the Pacific Islands Families
(PIF) study, this research is able to access longitudinal data and provide empirical
evidence on kava that currently has little quantitative research data available. One of
the main motivators for this study was due to members of the public; social agencies
employees, family members, and friends of the author sharing their concern over kava
usage and independently referred to the situation as “kava is destroying families”.
The thought of a threat to Pacific families was sufficient to prompt the author to
investigate the matter further.
1.1 Kava and culture
Figure 1
1 Kava (botanical name - Piper Methysticum) is a beverage that is consumed both
socially and traditionally in many Island nations in the Pacific. Turner (1986) suggests
that for Pacific, rituals were conducted to communicate with spiritual realms in which
kava was the medium consumed to enhance this communication (Refer Figure 1).
When Missionaries arrived in Fiji, part of their desire was to change traditional beliefs
and have the locals embrace the missionaries’ religion, which meant discouraging the
use of kava and its practices (Kava, 2001). In Fiji, Sevusevu (kava presentation ritual)
is a component of all rituals relating to; culture, all living things, ancestral links, and
varying forms of spirituality (Shaver & Sosis, 2014). In Samoa, an ‘Ava (kava)
ceremony will take place for all formal occasions including the bestowal of a chief’s
title, entertaining revered guests, and for all significant gatherings. In Tonga, kava
ceremonies are seen as a reinforcer of cultural values and ideology. According to Her
Royal Highness Princess Salote Mafile’o Pilolevu Tuita when speaking of the Royal
kava ceremony, she relays that kava has special significance to Tongans because it
symbolises allegiance, solidarity, the commitment of Tongans to their country, echoes
and imparts culture, and reasserts loyalty to each other and also to the King (Smith,
2011). Polynesian scholar Futa Helu conveys that customary rituals such as kava
ceremonies are not only about learning within ones cultural sphere, but also invites
others to learn about that particular society and, Helu deems kava ceremonies as the
centrepiece of Tongan culture and rituals (Smith, 2011).
Many rituals are derived from myths and legends. According to Tongan folklore, kava
is interwoven with sacrifice, and devotion (Turner, 1986). The myth as told in Smith
(2011) conveys the story of a poor young couple (Fevanga and Fefafa) that lived on
the small island of ‘Eueiki with their young daughter (Kava) who was afflicted with
leprosy. Unexpectedly the King and his men arrived on the Island for rest and
refreshment. The giant taro was the last source of nutrition on the island so Fefafa
went to collect it while Fevanga went to ready the underground oven. When Fefafa
arrived to harvest the giant taro she was horrified to see the king asleep on top of the
taro plant. As it is inappropriate for her to approach the divine king, she runs back and
tells Fevanga her dilemma. Because of the couple’s deep sense of duty and the lack of
food, they sorrowfully offered up their cherished daughter as a sacrifice and placed
her in the underground oven. When the king heard of this ultimate sacrifice and
devotion he was saddened and left the island immediately. The underground oven had
2 now become Kava’s grave. Some time later two strange new plants appeared on the
burial mound. One appeared at the head of the mound and was sweet, the other at the
foot of the mound and had a bitter tasting root. The couple made a presentation to the
king of the plants as a token of their sacrifice, and loyalty. The bitter plant was to be
called ‘Kava’ after the young girls sacrifice and her parent’s love, and the other ‘To’
or sugar cane. Hence the drink made from the root of the kava became the ceremonial
drink of Tonga, a symbol of sacrifice.
A fundamental value in Tongan society is sacrifice that is often shown through love –
the truest form of sacrifice, and is acknowledged through repetition in kava
ceremonies (Culbertson, Agee, & Makasiale, 2007). Helu believes kava was
originally used as part of ancient religious rituals but has since been socialised to keep
order in society. “It seems to me that human sacrifice was fairly common in ancient
times” (Smith, 2011).
In Vanuatu kava consumption is widespread and has been a part of the culture for
millennia (Grace, 2003). Lebot, Merlin, and Lindstrom (1992) suggest that kava has
been harvested in Vanuatu as long as 2500-3000 years ago. In Grace (2003), their
descriptive study found that 1 in 2 Vanuatu men drink kava at least weekly with 1 in
10 drinking kava daily. Vanuatu has been a source of kava supply for many Pacific
nations and Western investors as kava’s medicinal, recreational, and social features
are sought (Lindstrom, 2009). As Vanuatu succumbs to Western influences, there is
an increase in the amount of women drinking kava and kava consumption is taking on
a more casual aspect (Grace, 2003).
For some cultures in the Pacific Islands, kava consumption appears to be at the
forefront of local beverages. Kava consumption appears to provide a socialized
environment with an enhanced spirit of closeness between consumers brought about
by the collective consumption of kava. Moreover, kava maintains its distinctiveness
as a revered beverage used for ceremonial purposes that enhance opportunities for
Pacific to honour cultural traditions, adhere to protocols, support one another,
socialize, and share information. Faikava practices in the Tongan culture are steeped
in traditional elements and protocols and are considered a “culturally appropriate
outlet” for conflict resolution, and also provide an opportunity for social hierarchy
3 boundaries to be crossed (Fry, & Bjorkqvist, 1997). The protocols surrounding kava
ceremonies are similar across the cultures of the Pacific with the role of kava in
Pacific Island culture being one of significance and reverence depending upon the
occasion (Refer Figure 2). Kava indicates the importance of a particular celebration
as special occasions and celebrations are not complete without a kava ceremony
(Victoria University, 2013). Moreover, kava is more to Pacific than a beverage, it is a
way of life and, for some Pacific living in Auckland it is a way of keeping their
culture alive.
Kava from plant to drink
Kava Plant
Root Stock
Mix with water
Ground Kava
Drink
Figure 2
1.2 Biochemistry of kava
1.2.1 Kava and its chemical makeup
Kava is a pepper plant grown throughout the South Pacific. It has many names
including: Ava, Awa, Waka, Lawena, Grog, or Yaquona. Kava is a nonalcoholic
4 beverage made from the root of the Kava plant. Soil conditions, climate, and
environmental factors stimulate the potency and strain of the kava produced (Taki
Mai, 2012). Kava plants reach maturity at three to four years after planting although,
according to Singh (2004), harvesting the plants may be delayed as the larger the
rootstock of the plant, the increased concentration of kavalactone content.
Pharmacological activity in the body as a response to kava consumption is considered
to be the result of kavalactones. Captain James Cook gave the first documented report
on kava and its intoxicating effects that led to English scientists trying to isolate the
active ingredients which brought about this sedative effect (NYU Langone Medical
Centre, 2014). Through laboratory experimentation and extraction processes,
chemical synthesis of the following kavalactones has been reported (Refer Figure 3):
kavain, dihydro-kavain, dihydromethysticin, methysticin, 5,6-dehydromethysticin,
demethoxyyangonin, 11-methoxyyangonin, 11-methoxynoryangonin, and yangonin
(Israili & Smissman, 1976; Lebot, Merlin, & Lindstrom, 1992).
Kavalactones
Figure 3
Approximately 18 kavalactones are believed to be psychoactive and therefore cross
the blood-brain barrier and act on the central nervous system altering brain
perception, cognition, mood, and behavior, resulting in muscle relaxant, anxiolytic,
5 anaesthetic, and anticonvulsive effects (Cairney, Maruff, & Clough, 2002). When
conducting research on kava, two main formulations of kava are used including: resin
that appears to paralyse sensory nerves and is a local anaesthetic; and kava root
extract. This water-soluble formula decreases activity in mice (Sharma, Bautam, &
Gharami, n.d.).
Lader, Cardinali, and Pandi-Perumal (2006); and Cairney, et.al, (2002), identify
kavalactones mechanisms through which biological change is initiated. First:
kavalactones facilitate the neurotransmitter gamma-Aminobutyric acid (GABA)
transmission through the GABA-Chloride (Cl-) ion channel by enhancing an influx of
Cl- into post-synaptic cells, making the inside of the cell somewhat more negative and
therefore inhibiting a post-synaptic potential (IPSP) (Saffarzadeh, 2012). This may
affect short-term memory and produce a decrease in pain reception. Second: Several
areas of the brain are affected by the inhibitory actions of GABA including the motor
cortex, reticular activating system, and the limbic system (Hanson, Venturelli, &
Fleckenstein, 2012). Binding is not conducted through the benzodiazepine receptor as
with anti-anxiety drugs such as Valium or Librium thus highlighting the fact that kava
is not competing with other drugs for the same binding sites and therefore can have an
additive effect (Saffarzadeh, 2012). Although binding in the post-synaptic cell is
different, the effect of kava on the nervous system is similar to that of
Benzodiazepine. For example, both kava and Benzodiazepines may affect mood via
the limbic system, alter reticular activating system function to cause drowsiness, and
relax muscles through cortical function (Hanson, Venturelli, & Fleckenstein, 2012).
Third: Kavalactones effect monoamines and block the reuptake of norepinephrine.
Norepinephrine Reuptake Inhibitors (NRIs) are often used to treat mental health
disorders such as Major Depressive Disorder, fibromyalgia, and neuropathic pain
such as phantom limb syndrome (Halter, 2014). Kavalactones also have an effect on
dopamine and serotonin levels however; the evidential findings suggest that the
fluctuation in dopamine and serotonin levels is dependent upon which kavalactone is
being tested (Lader et al., 2006).
According to Simeoni and Lebot (2002); Whitton, Lau, Salisbury, Whitehouse, and
Evans (2003), tissue samples were taken from 5-year-old and 8-year-old roots and
although the older tissues had a higher concentration of kavalactones in the bark, it
6 had lower concentrations in other tissues making it slightly more diluted across the
rootstock as a whole. An analysis of the fresh rootstock revealed it consists of 80
percent water yet when the rootstock is dried (Refer Figure 4), water content reduces
to 12 percent with the remaining 88 percent made up of 3.2 percent minerals, 3.2
percent sugars, 3.6 percent protein, 20 percent fibres, 43 percent starch, and 15
percent kavalactones which dependent upon the age and cultivation of the plant could
vary between 3 and 20 percent (US Department of Health and Human Services
[USHHS], 1998). The kava beverage is made when the rootstock is ground to a
powder, then mixed with water and strained through cloth into a kava bowl. Once
consumed, the effect of kava is immediate.
Dried Rootstock Composition Fibres Water Starch Kavalactones Figure 4
1.3 Kava Extraction
Interest in the psychoactive actions of the kavalactones has led to many experiments
to extract the kavalactones from the kava plant. Pacific people have consumed kava
for centuries with little or no clearly evidenced health related issues. According to
Whitton et al. (2003), the adverse effects come from the use of extracts and
specifically the extraction process. Quality of kava either consumed traditionally or in
other forms is determined by six kavalactones being present: methysticin,
dihydromethusticin, kavain, dihydrokavain, yangonin, and desmethoxyyangonin
(Wang, Qu, Bittenbender, & Li, 2013). Solvents used in the commercial extraction
process of kavalactones are either ethanol or acetone which were only effective at
extraction when >80% of either medium was used to produce 100% kavalactone
extracts (Whitton et al., 2003). Wang, Qu, Bittenbender, & Li (2013) found that
extracting kavalactones from kava beverages found kavain to be the dominant
7 kavalactone in the Mahakea root beverage, however total kavalactone content in the
Isa root beverage was two-fold of the Mahakea beverage. This suggests that kava is
best consumed in its aqueous state.
1.4 Kava Classification
According to Lindstrom (2009) up until the 1990s kava was consumed mostly within
Pacific Island nations however, over the next decade as kava became popular for its
usage as an alternative medicine and its psychoactive effects, the kava market in
Vanuatu burgeoned. Kava was classified as “non-narcotic, non-opiate, nonfermenting, non-alcoholic and physiologically a non-addictive beverage” (Leung,
2004; Chanwai, 2000). However, several researchers would disagree with this
classification and view it as a narcotic with psychoactive mind-altering properties
(McDonald & Jowitt, 2000; Singh, 2009). Aggressive kava distributors use the nonnarcotic classification to their advantage by highlighting the benefits of kava and
promote its use without mentioning any possible side effects (Kava, 2001). This
classification has also enabled Health food stores to supply kava in the pill form as an
alternative to pharmaceutical medicines (Chanwai, 2000). It may also be considered a
safe alternative to alcohol.
1.5 Kava versus Alcohol
Nosa and Ofanoa (2009) identified four elements that contribute to the reasons men
drink kava which include: social outing, making and solidifying friendships, status
associated with the kava plant and, as an alternative to alcohol. Kava is often
compared with alcohol in relation to its effects especially the non-aggressive emotions
experienced by kava consumers. In Vanuatu 50 surgical patients, 50 medical patients,
and 50 staff members were surveyed to gain an understanding of their kava
consumption habits (Grace, 2003). Their findings showed that at least 1 in 3 adults
consumed kava at least weekly, and those who were heavy users presented with kava
dermopathy and were underweight. This was not considered as a health hazard as
both could be rectified in the decrease of kava consumption and the lower body
weight was seen as beneficial in a culture where Pacific are seeing increases in
8 obesity a major risk factor for cardiovascular disease and diabetes. Grace (2003)
suggested that with the lack of medical evidence pertaining to negative impacts of
kava, it might be viewed as a preferred alternative to alcohol.
In the early 1980s kava was introduced to the Aboriginal communities in Arnhem
Land in the Northern Territory of Australia as an alternative to alcohol (Prescott,
1990; Cairney, Maruff, & Clough, 2002). With little literature or evidence in relation
to the effects of kava consumption, it was deemed a viable option to the adverse
effects experienced in the Aboriginal communities from heavy alcohol consumption.
However, Aboriginals in Arnhem Land consumed extremely high amounts of kava
compared to Pacific and without the traditional and social context of Pacific usage
(Clough, Burns, & Mununggurr, 2000). The heavy kava usage has allegedly
culminated in adverse effects on Aboriginal consumers (Prescott, 1990; Cairney,
Maruff, & Clough, 2002). A State awareness of this plight led to laws restricting the
importation of Kava into Australia unless it is for cultural use of Pacific, and this is
limited to 2kg (Australian Government Department of Health, 2011). Kava usage out
of its traditional context and consumed in a variety of ways has appeared to bring with
it health challenges for some consumers.
1.6 Beneficial Effects of kava
People of the Pacific have utilised kava and its healing properties for eons
(Lindstrom, 2009; Smith, 2011). The use of kava has proven to be beneficial for
treatment in areas such as anxiety, stress related disorders, and stress-induced
insomnia (Cropley, Cave, Ellis, & Middleton, 2002). Clinical trials suggest kava is
effective for treating anxiety (Cassileth, 2011). Meta-analyses of placebo-controlled
studies on patients with anxiety showed significant reductions on those receiving
300mg/day of kava over a four-week period compared to those receiving a placebo
(Rowe, Zhang, & Ramzan, 2011). A Cochrane review of 11 Random Control Trials
(RCTs) using kava monopreparations (60mg - 280 mg of kavalactones) in the
treatment of Generalised Anxiety Disorder (GAD) showed statistically significant
anxiolytic activity for those receiving kava as opposed to those in the placebo group
(Sarris & Kavanagh, 2009).
9 Wheatley (2001) conducted a small study with a sample of 19 participants, exploring
the effects of kava and valerian on stress-induced insomnia. Patients identified as
exhibiting insomnia brought on by stress were given a six-week course of kava
(120mg per day), a two-week break, and then a following six-week course of valerian
(600mg per day). Measurements of stress were conducted across three areas: lifeevents, personal, and social. Insomnia was also measured across three areas: time to
fall asleep, hours slept, and waking mood. Results showed that kava significantly
relieved both the stress and the insomnia (p<0.01). The rapid relief of symptoms
experienced by participants whilst taking kava, with little change occurring during the
two week break and then valerian treatment, suggest kava may be a catalyst in
bringing about permanent change in these areas however, this would need to be
researched further (Wheatley, 2001). Wheatley (2001) found kava to be “undoubtedly
effective” in this study with properties beneficial for treatment of sleep disorders and
anxiety related dysfunction. In a single case study on a 38-year-old female, it was
found that a combination of kava extract and Cognitive Behavioral Therapy (CBT)
were successful in the treatment of panic attacks (Dattilio, 2002).
For Pacific, the kava session itself brings with it benefits also. A psychological benefit
via the opportunity to express feelings and discuss matters of concern amidst a
brotherhood relieves any built up frustrations and facilitates conflict resolution (Fry,
& Bjorkqvist, 1997). These findings all suggest that the need for further study into the
implementation of kava as an intervention may be useful. However, not all studies
and experiences show beneficial effects with little or no side effects.
1.7 Adverse effects of Kava
When kava exports grew in the 1990s concerns arose over its safety. By 2002 several
European countries banned kava importation as links were being made between kava
usage and liver dysfunction (Lindstrom, 2009). Although kava has shown positive
results for the treatment of anxiety, GAD and other depressive disorders, it has been
found to be contraindicated for endogenous depression as the altered psychological
state may increase the likelihood of suicide (Dattilio, 2002). Moreover, kavalactones
are potent inhibitors of specific enzymes that may lead to serious pharmacokinetic
drug interactions (Anke, & Ramzan, 2004). The United States Food and Drug
10 Administration (FDA) has issued a warning about potential risks of liver dysfunction
from kava consumption, and the World Health Organisation (WHO) has made
recommendations for further research to be conducted on the aqueous extracts of kava
(Cassileth, 2011). In New Zealand there is very little quantitative evidence relating to
the adverse effects of kava consumption. A case study at Middlemore Hospital, New
Zealand, provides some insight into the adverse effects of kava usage.
1.7.1 Case Study
Dr Giles Chanwai reported on the admission of a 34-year-old Tongan male (Pt X) to
the Emergency Department at Middlemore Hospital (Chanwai, 2000). Pt X had
moved to New Zealand about a month prior and after a night of binge drinking kava,
was found by family members very unwell and complaining of sore eyes, headache,
generalized muscle weakness, disorientation, hallucinating, and abdominal pain.
Upon examination he was disorientated around time and place but spoke clearly and
followed commands albeit slowly. He was unable to walk or stand, exhibited scaly
skin on hands and feet, had little amount of fat over moderate muscle mass, had
bloodshot eyes, and experienced muscle weakness in the limbs. Prior to Pt X’s
admission he reported to being generally well but also communicated to staff that he
drank up to 40 bowls of kava per day over the past 14 years. Diagnosis was “kava
intoxication on a background of chronic kava consumption” and treated with
Plasmalyte intravenously and a single dose of thiamine upon which he improved
(Chanwai, 2000).
The reaction Pt X had to excessive kava consumption may be a result of what is
termed Pavlovian conditioning and drug tolerance. Although kava is considered a
non-narcotic, the consumer does experience a physiological response. Many
Pavlovian experimental studies have been conducted in laboratories with an array of
animals. One such experiment was conducted by Siegel (2001) to test drug tolerance
in specific environments. “’Situational-specificity of tolerance’ was found to develop
after a series of drug administrations in the presence of drug-associated cues” (Siegel,
1976). Siegel’s studies found that conditioned responses were stimulated in situations
where drug associated cues were present and consequently the effect of the drug
lessened. This enables drug users to increase the amount of drug dosage with little
11 effect in the same situation or context. However, when the situation, context or
environment is altered, drug-associated cues will no longer be present and may lead to
an overdose, as the body is not prepared for the drug dosage. Gutierrea-Cebollada, de
la Torre, Ortuno, Garces, and Cami, (1994) conducted studies on heroin overdose and
also highlighted drug usage in an unfamiliar place is a risk factor for overdosing. In
the case of Pt X being admitted to Middlemore Hospital with kava intoxication, a
possible reason for this may be that he was used to consuming a large amount of kava
over a prolonged period of time in his native Tonga. Except, when Pt X relocated to
New Zealand, the context in which he consumed kava altered. There were no precursors to prepare the body for kava intake as per usual that unwittingly lead to a
heightened physiological response and subsequent admission to hospital.
Another aspect may be in relation to acculturation. Acculturation entails people of
varying cultures and backgrounds, coming together and altering their life long
behavior and culture culminating in a new society (Sam & Berry, 2006). According to
Jackson (2006), early ideology surrounding acculturation considered assimilation to
be the ideal form of acculturation as migrants would be better to embrace the new
culture and leave behind their own to eliminate acculturative stress. However,
contemporary research suggests that preserving one’s heritage and belief systems
leads to better adaptation (Jackson, 2006). A fourfold approach to acculturation
portrays the way in which an immigrant may respond to their new cultural
environment. The four areas are defined as: assimilation – the individual embraces the
new culture and belief systems over their own culture; separation – the individual
holds firmly to their culture of origin; integration – the individual finds balance
between both original and new culture developing biculturalism; and marginalization
– the individual rejects both cultures for various reasons (Rudmin, 2003).
Moving to a new country may be extremely stressful especially when there are
language barriers to overcome. Ward (2001) suggests that three specific psychological
areas are effected during the migration process including: stress and coping; cultural
learning; and social identification. According to Berry, Kim, Minde, and Mok (1987),
immigrants face psychological and behavioural changes which may include adjusting
to a new language, clothing differences, and dietary variances that may be
experienced as minor behavioural changes or at the extreme, problematic adjustment
12 causing ‘acculturative stress’. Acculturative stress may manifest in a variety of ways
including depression, angst, and insecurity (Sam & Berry, 2010). It is possible that
due to the acculturation process that Pt X was undergoing, he may have been
experiencing acculturative stress with a heightened biological response to the kava
consumed despite kava consumption having little effect prior to migration.
Pt X’s amplified biological reactions subsided once treatment was delivered
(Chanwai, 2000). Pt X exhibited prominent scale-like effects that erupt on the skin is
sometimes known as kava dermopathy (Refer Figure 5).
1.7.2 Kava Dermopathy
Figure 5
Guro-Razuman, Anand, Hu, and Mir (1999), found that kava dermopathy is a
reversible skin disorder that is found to occur in kava consumers when large amounts
of kava are consumed over a prolonged period of time. A survey on males in Tonga
found that out of 200 participants, 29 presented with noticeable kava dermopathy
(Ruze, 1990). Causation for this kava dermopathy is unclear although some theories
suggest lymphatic attacks on sebaceous glands leading to necrosis, and others suggest
interference with B vitamin metabolism (Glover, 2007). Ruze (1990) found
associations between pellagroid dermopathy and heavy kava consumption may be
linked to niacin deficiency. Adverse effects of kava consumption have been gaining
momentum in research arenas with studies exploring heart disease, lung capacity, and
liver toxicity.
13 1.7.3 Hepatoxicity
As the studies are showing, the adverse effects that kava is having on the
physiological stasis of the body is clearly related to the amount of kava consumed,
frequency, duration, dosage, and substantial usage. Most biological dysfunction
appears to dissipate with a reduction in kava consumption. Kava hepatotoxicity is a
liver injury induced by the consumption of kava whether commercial products or
traditionally prepared beverages (Teschke, 2010). According to Rasmussen (2005),
and Food Standards Australia New Zealand (2004), approximately 80 worldwide
cases of liver damage have been linked to kava however; there have been no known
reports of this in communities where indigenous people have traditionally used kava
despite the large amounts consumed. In the study conducted by Teschke (2010),
attention was drawn to specific factors that are unable to substantiate definitive claims
regarding a kava hepatotoxicity classification due to: confounding variables such as
quality of kava plants, parts of plant used, dosage, duration, and low numbers of
patients who are diagnosed with kava hepatotoxicity. Therefore it may be suggested
that the adverse effects documented pertaining to liver dysfunction may be attributed
to the artificially prepared commercial products as opposed to the traditional water
infused extracts (Rasmussen, 2005; Food Standards Australia New Zealand, 2004).
Moreover, evidence provided by the Whitton et al. (2003) study suggest that
hepatotoxicity may be due to enzymatic issues needed for clearing commercially
extracted kavalactones by the liver.
1.7.4 Kava dependency
There is very little empirical evidence available in relation to whether kava has
addictive components. Marshall’s 1987 study (as cited in Prescott, 1990)) suggests
that although kava may be consumed in the Pacific Islands over a prolonged period of
time, there is little evidence of physical symptoms of withdrawal however, he does
note that there is an emotional yearning for the social aspects related to Kava
consumption. According to Prescott (1990), Aboriginals living in Arnhem Land
communities show numerous adverse health effects from Kava consumption. These
include not only the kava dermopathy but also; breathing difficulties, abnormalities in
14 the blood, dysfunction of liver and kidney, weight loss, and bloodshot eyes (Prescott,
1990). Although these findings do not currently reflect consumers in New Zealand
(NZ), this may be due to little empirical evidence being available on kava
consumption in NZ. Kava consumption does not only have physical consequences,
there are also psychosocial factors that are affected.
1.7.5 Mental Health
According to Makowska, Merecz, Moscicka, and Kolasa (2002), it has been
suggested that there is an increase in the prevalence of mental health disorders across
various populations resulting in significant individual and societal costs. Furthermore,
this cost increases when mental health disorders also present with somatic diseases. In
New Caledonia, kavalactones were found present in people who had committed
suicide leading to a study on young Kanaks, their kava drinking, and its connections
with suicidal behavior (Vignier, Lert, Salomon & Hamelin, 2011). The study was
conducted with the utilization of a community-based survey and administered crossculturally to 1,440 people aged between 16-25 years. 42% of respondents registered
Kava consumption of which 34% reported suicide ideation with 12% having
attempted suicide (Vignier, Lert, Salomon & Hamelin, 2011). This particular study
concluded that kava consumption increased the likelihood of reporting both suicide
ideation and attempts, whilst also acknowledging that the difference between the kava
consumption effects on Kanak youth and others may be due to the patterns and
quantities of kava consumed. These findings raise concerns not only on the
consumption of kava, but also the psychosocial factors that contribute to the drinking
of kava.
1.7.6 Psychosocial aspects of Kava
Kava can be viewed as a medium for nurturing ones own self-exploration, analyzing
ones place in the community, insight into environmental factors that influence
perceptions, and self awareness of effective interpersonal relationships. Socialization
and interaction amongst kava consumers is an important aspect in the overall kava
experience. According to Sharma et al. (n.d.), kava brings an enlightened aspect from
15 which to view the world, enhanced well being, and harmony with community, self,
and the environment. The psychosocial aspects of kava significantly influence the
consumption of kava. As stated in Prescott (1990), when one decides to go without
kava for a time, there are little if any physical withdrawal symptoms but there is
considerable withdrawal noted in relation to the sense of loss over the lack of social
interaction with other kava consumers. Kava traditions and protocols foster an
environment where disharmony is negated, information is shared, and feelings are
valued enhancing feelings of trust and belonging (Lemert, 1967).
In New Zealand a survey on 12 Tongan men, Nosa and Ofanoa (2009) found that
binge-drinking kava was commonplace and entailed drinking from late at night to the
early hours of the morning, having a detrimental effect on the KU’s family. Nosa and
Ofanoa (2009) add that their KU participants acknowledged that after consuming
kava they felt lethargic and needed a whole day to recover from the effects of kava.
Some participants in their study indicated that this negative effect manifested in the
form of domestic conflict resulting in family court action and broken homes (Nosa
and Ofanoa, 2009).
In Fiji some of the smaller communities experienced difficulties as a result of village
men over indulging in kava, which led to an investigation into the side effects of kava
consumption. The side effects explored were not the personal physical effects
experienced by the kava consumers, but those felt by their families and the wider
community. The study focused on male consumers as overall male usage is
substantially higher than females (Finau, Stanhope, & Prior, 1982). Kava (2001)
conducted a study that included interviews with 300 male kava drinkers, their wives,
employers, and local marker vendors. The negative effects included; market vendors
selling approximately 1.5 tons of Kava per week with a market value of $60,000
which comes from males spending up to 20% of their household income on kava; due
to heavy kava consumption employees are late for work impacting on their
employability; wives are feeling neglected and are not given enough money to
provide for the basic needs of the family as a result of the husband spending money
on kava; wives have to seek work opportunities and therefore not be at home to raise
the children; children of kava consumers are underachieving at school because of the
lack of school stationery and decreased parental supervision (Kava, 2001). The
16 Methodist church in Fiji has also raised concerns over the negative impact that after
church grog (kava) parties are having on families. Parents are leaving children at
home to attend functions and an increase in sexual assaults on young children, has led
to an investigation into the social causes and parental responsibility being addressed
(Tawakilagi, 2013).
The conclusion of the Kava (2001) study identified that men justified their heavy kava
consumption on the need for relaxation, improved sleep, better urinary flow,
enhanced sexual drive, decrease high blood pressure, and socialization with other
male consumers. However, this is contradictory to what the wives reported as they felt
their sexual needs were not met due to loss of sex drive from the husband and
impotence in some cases which led to extramarital affairs which increases the
likelihood of other complications (Kava, 2001; Sharma, Bautam, & Gharami, n.d.).
The data provided by Kava’s 2001 study brings awareness to the negative health and
social impact that heavy Kava usage has on Kava consumers, their families and, the
wider community. This corroborates the findings of Matthews, Riley, Fejo, Monoz,
Milns, Gardner, Powers, Ganygulpa, and Gununuwawuy (1988) when studying the
effects of heavy kava usage on Aboriginals in Arnhem Land found strong support for
the need of social intervention and education on the consumption of kava and the
health risks associated with its use including nutritional deficits, decreased lung
capacity, and blood dysfunction.
Nosa and Ofanoa (2009) highlight the psychosocial issues that are arising within New
Zealand as kava consumption increases. With kava being far more accessible on a
global scale, promoted as a safe health product, and brought into communities
previously unfamiliar with kava usage, awareness needs to be made in many facets of
care when dealing with kava users (KU) (Chanwai, 2000).
1.8 Aim of the study
The aim of the current study was to assess Pacific Islands Families study data, and
identify patterns of Kava usage with subsequent effects on Pacific families living in
South Auckland. With the focus being solely on Pacific Island males, it was important
to gather specific Kava information, which was purposefully obtained in Year 1 and
17 Year 11 data collections. This data would then be examined to gain insight into Kava
culture and how Kava consumption may change over a ten year period.
CHAPTER 2: METHODS
18 2.1 Pacific Islands Family Study
Data was retrieved from the Pacific Islands Families (PIF) Study; a longitudinal birth
cohort study of infants born at Middlemore Hospital in Auckland between 15 March
and 17 December 2000, that was developed through the combined efforts of social
agencies, researchers, Pacific communities, and those with a vested interest in social
and scientific research within the Pacific Island communities (Paterson, Percival,
Schluter, Sundborn, Abbott, Carter, Cowley-Malcolm, Borrows, and Gao, 2007). The
aim of the PIF study was to gain knowledge where currently there was very little in
relation to the “health, psychosocial, and behavioural characteristics” of Pacific living
in New Zealand with young child/ren (Paterson, Tukuitonga, Abbott, Feehan, Silva,
Percival, Carter, Cowley-Malcolm, Borrows, Williams, and Schluter, 2006). The
study endeavoured to capture the experiences of mothers, fathers, and children in
identifying individual health and wellbeing, core ideologies and mechanisms that
contribute to health, and to take this knowledge to help guide future initiatives to
improve Pacific families health, wellbeing, and society as a whole (Paterson et al.,
2007).
2.2 Participants
Identification of potential participants and consent was conducted through the
Birthing Unit at Middlemore Hospital and in conjunction with the Pacific Islands
Cultural Resource Unit (Paterson, Taylor, Schluter, & Iusitini, 2012). Initially only
mothers were interviewed although permission was obtained from the mother for the
father, secondary or collateral caregiver of the child to be contacted and interviewed
(Paterson, et al., 2006). Some of these caregivers may have identified as female, nonPacific or the parent of twins (interviewed for each child). The year 1 cohort consisted
of 825 fathers that also included non-Pacific. However the data set was organized to
exclude all non-Pacific fathers, or females, and to only include one set of data per
person. This was to ensure that fathers of twins would only have their questionnaire
answers entered once and therefore not compromise the validity of the data. With the
present study targeting kava usage, questions relating to this topic were used in year 1
and year 11 from which our data is obtained.
19 For consistency in the present study, all participants may be referred to as ‘fathers’,
however we acknowledge that not all participants are the biological fathers although
they are the secondary caregivers for the child.
2.3 Measures
The PIF study contained three specific areas in which this present study focused on.
These included the questions surrounding kava, ethnicity/acculturation, and
psychological wellbeing. The PIF adapted three previous measures to fit the criteria
and suitability for Pacific. Kava questions derived from Alcohol Use Disorders
Identification Test (AUDIT), questions pertaining to ethnicity and acculturation were
adapted from the General Ethnicity Questionnaire (GEQ), and health and wellbeing
questions were utilized from the 12-item General Health Questionnaire (GHQ-12).
The AUDIT is a screening measure that was developed to help practitioners identify
clients who were experiencing a negative impact on their lives by their alcohol usage
(Barbor, Higgins-Biddle, Saunders, & Monteiro, 2001). The AUDIT is a screening
measure and therefor whether being used for alcohol or kava consumption, it is not a
measure for diagnosing alcohol or kava related disorders but merely as a way to
screen for consumption, attitudes, and related risks (Barbor, Higgins-Biddle,
Saunders, & Monteiro, 2001). By utilising AUDIT in the PIF study in relation to
kava, it allows for researchers to identify the frequency of kava consumption, the
amount of kava consumed, who kava is consumed with, and if kava consumption is a
concern for significant others.
The GEQ was developed with a view that it would be an efficient measure of
acculturation cross-culturally by simply altering the reference culture (Tsai, n.d.). The
GEQ was formulated by adapting four existing acculturation measures: Cultural Life
Styles Inventory, Acculturation Rating Scale for Mexican America and, Suinn-Leww
Asian Self-Identity Acculturation Scale, and Behavioural Acculturation Scale (Tsai,
n.d.). The GEQ was modified to capture specific areas relevant to Pacific and the
appropriateness of the scale to the New Zealand society (Schluter, Tautolo, &
Paterson, 2011). This entailed abbreviating and adapting the questionnaire, which
subsequently led to the development of the New Zealand (NZACCULT) and Pacific
20 (PIACCULT) versions of the GEQ and focused on major areas; heritage, culture, and
identity; and involvement and interactions in the wider society (Borrows, Williams,
Schluter, Paterson, & Helu, 2011). The NZACCULT modifications included
questioning in areas such as: friendships, understanding of English language, sport
and recreation, religious practices, food, being brought up the New Zealand way and
so forth, whilst the PIACCULT focused on how the questions were presented to the
participants and the connection participants still had with their Pacific culture of
origin (Schluter, Tautolo, & Paterson, 2011).
The GHQ-12 was developed in England as a screening instrument to identify
psychological distress among adults in primary care settings. The GHQ-12 has shown
efficacy cross culturally and is a multidimensional scale that reliably identifies
various aspects of distress (Sanchez-Lopez & Dresch, 2008). With good specificity
and sensitivity, the GHQ-12 is a good international measure for assessing general
health and, mental health and wellbeing (Tautolo, Schluter & Sundborn, 2009). The
GHQ-12 was utilized in the PIF study to gauge psychological distress in participants
(Tautolo, Schluter & Sundborn, 2009).
2.4 Data Analysis
All statistical analysis was conducted through Statistical Package for the Social
Science (SPSS) version 22 software. Descriptive statistics were used to obtain
frequency data and bivariate analysis was performed using cross tabulation on SPSS.
Pearson’s Chi-square tests were conducted to test bivariable associations and p<0.05
was used to indicate significance.
21 CHAPTER 3: RESULTS
3.1 Cohort Sample Characteristics
Ethnicity
The cohort consisted of 766 fathers in year 1 which decreased to 716 in year 11. In
both year 1 and year 11 the majority of the participants were Samoan (n=440/n=375)
with the second largest ethnic group represented by Tongans (n=199/n=197). Cook
Islanders although the second largest Polynesian population in Auckland was
represented with the third largest group with (n=73/n=89). The remaining Pacific
ethnicities were grouped into one categorized ‘other Pacific’ (n=54/n=55) (Refer
Table 1).
Table 1
Year 1
Samoan
Cook Island
Tongan
Other Pacific
Total
Year 11
n
%
n
%
440
57.4
375
52.4
73
9.5
89
12.4
199
26.0
197
27.5
54
7.0
55
7.7
766
100
716
100
In both Year 1 and Year 11 the predominant ethnical representation was by the
Samoan population notwithstanding a decrease of 65 participants. The Cook Island
population increased whilst Tongan and other Pacific remained relatively stable.
Age
In year 1 the father’s age ranged from 17-65 years with a mean age of 32.11 and
standard deviation (SD) of 7.29. In year 11 father’s age range was 22-71 years, mean
age 42.53, SD 7.95 (Refer Table 2).
22 Table 2
Year 1
Year 11
n
%
n
%
17-29
296
38.64
15
2.09
30-39
363
47.39
254
35.47
40-49
85
11.10
323
45.11
50-59
20
2.61
96
13.41
2
0.26
28
3.91
766
100
716
100
60+
The majority of participants in Year 1 were 30-39 age group which is clearly reflected
in Year 11 as the group 10 years later is the 40-49 age group. The 17-29 age group
also shows a similar trend with both groups decreasing by approximately 40
participants by Year 11.
Acculturation
Acculturation identified which classification best described the participants
experience when adjusting to New Zealand societal constructs (Refer Table 3).
Table 3
Acculturation
Year 1
Year 11
n
%
n
%
Assimilation
251
32.8
219
32.4
Separation
301
39.3
197
29.1
Integration
74
9.7
87
12.9
132
17.2
173
25.6
766
100
676
100
Marginalisation
In Year 1 participants identified Separation and Assimilation as the two most
identified acculturation classifications. However, by Year 11 Separation had
23 decreased, Assimilation and Integration remained relatively stable, furthermore the
largest increase was depicted by an increase in Marginalisation from 17.2% to 25.6%.
Psychological Distress
On the GHQ-12, participants were categorized into either non-symptomatic in which
they were not experiencing symptoms related to psychological distress, or if they
were, they were classified as symptomatic (Refer Table 4).
Table 4
Psychological Distress
Year 1
Non-Symptomatic
Symptomatic
Year 11
n
%
n
%
747
97.6
634
92.4
18
2.4
52
7.6
Table 4 shows that in both years the majority was non-symptomatic (n=747/n=634)
with significantly less numbers being symptomatic (n=18/n=52). Increases were
shown in the symptomatic category with Year 1 (n=18) tripling to Year 11 (n=52).
3.2 Outcomes – Descriptive Statistics
Is Kava User (KU)
Frequency tables were constructed to ascertain what portion of participants were kava
users (KU) and what percentages were not. In Year 1 the total participants numbered
n=766 of which n=68 (8.9%) were KUs. In Year 11 participant numbers decreased to
n=716 of which n=176 (24.6%) were KUs. The prevalence of KUs has significantly
increased (p<0.001) over this ten-year period (Refer Table 5).
24 Table 5
Year 1
Year 11
n
%
Total
n
%
Total
No
698
91.1
766
540
75.4
716
Yes
68
8.9
100
176
24.6
100
The identification of KUs and exploring patterns was evident as we see within the
data that numbers are increasing in favour of KU however, it is also clear that the
majority of participants are non KUs.
How often Kava is consumed
To look into whether patterns would emerge surrounding kava usage, some form of
baseline needed to be established. In order to achieve this SPSS was used to ascertain
frequency of kava usage. All areas have shown an increase with the greatest increase
in the drinking 1-2 times (n=16/n=49) per year followed closely by those who now
drink kava 2-3 times per week (n=6/n=37) (Refer Table 6).
Table 6
Year 1
Year 11
n
%
n
%
698
91.1
540
75.7
1-2 times a year
16
2.1
49
6.9
About once a month
16
2.1
34
4.8
About once a week
30
3.9
51
7.2
6
0.8
37
5.2
0
2
0.3
Did not use
2-3 times a week
Daily
Total KU
Total Participants
68
766
173
100
713
100
With participant numbers rising around KU, this table shows frequency is also
increasing. Greater portions of participants that consume Kava are now drinking at
least weekly with 2 participants consuming Kava on a daily basis.
25 Number of drinks consumed in a Kava session
Once frequency was established, it was important to then investigate the amount of
drinks consumed in a kava session. In Year 1 and Year 11 the majority of participants
consume an excess of 10 or more drinks per session (Refer Table 7).
Table 7
Year 1
Year 11
n
%
n
%
1 or 2
3
4.3
3
1.7
3 or 4
2
2.9
10
5.8
5 or 6
3
4.3
5
2.9
7 to 9
1
1.4
5
2.9
10 or more
61
87.1
150
86.7
Total
70
100
173
100
The quantity of kava consumed in a session has remained similar in both years
identifying 10 or more drinks as possibly the usual consumption amount.
Who Kava is consumed mostly with
Traditionally kava is consumed with others therefore the study investigated who KUs
consume kava with most, and also explore if any KUs consumed kava alone. In Year
1 kava is consumed mostly with friends (n=64). Family (n=54) and then community
groups (n=53) come a close second and third. In Year 11, friends (n=152) are still the
most common group in which to consume kava with however, community groups
(n=115) is now the second most common group followed by family (n=110). There is
also a small number of KUs drinking alone, which as this table shows, is not the norm
for kava consumption (Refer Table 8).
26 Table 8
Year 1
Alone
Family
Friends
Community Groups
Other
Year 11
n
%
n
%
No
66
95.7
170
23.7
Yes
3
4.3
4
2.3
No
14
20.6
64
36.8
Yes
54
79.4
110
63.2
No
4
5.9
22
12.6
Yes
64
94.1
152
87.4
No
15
22.1
59
33.9
Yes
53
77.9
115
66.1
No
28
41.2
145
84.3
Yes
40
58.8
27
15.7
766
100
716
100
Total
Friends are identified as the most common group with which Kava is consumed in
both Year 1 and Year 11 however, friends may also cross into the family and
community groups also which may make it difficult to clearly define in which
environment Kava is predominantly consumed.
3.3 Main Analysis of Associations
3.3.1 Associations of kava usage
Pearson’s Chi-Square tests were performed to establish relationships between two
categorical variables. This section investigates associations with kava usage and
other variables.
Ethnicity and Kava Usage
Exploration was done in the area of ethnicity in order to understand if particular
ethnic groups were more likely to be KUs than other Pacific groups. To achieve this,
ethnicity was crosstabulated with kava user (KU). Significant ethnic variations of
27 kava usage were found at both years (p<0.001). Tongan participants had the highest
number of KUs, with the amount of Tongan KUs increasing and outnumbering the
number of Tongan non-KUs by year 11 (Refer Table 9).
Table 9
Kava User crosstabulated by Ethnicity
Year 1
Year 11
No
Yes
Total
No
Yes
Total
Samoan
423
17
440
327
48
375
%
96.1
3.9
100
87.2
12.8
100
73
0
73
83
6
89
%
100
0
100
93.3
6.7
100
Tongan
151
48
199
84
113
197
%
75.9
24.1
100
42.6
57.4
100
51
3
54
46
9
55
%
94.4
5.6
100
83.6
16.4
100
Total
698
68
766
540
176
716
Cook Islands
Other Pacific
All ethnicities increased in their Kava consumption with over half of the Tongan
participants identifying as KUs in Year 11. This was up 33.3% from Year 1 (Refer
Figure 6).
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Not KU Yr 11 KU Yr 11 Not KU Yr 1 KU Yr 1 Figure 6
28 Age and kava usage
Investigating associations between KU and age was to identify the age range that had
the highest amount of KUs, and determine if that was reflected 10 years later in the
second collection of kava data in Year 11. In Year 1 the age range of 30-39 showed
the highest number of KUs with n = 42 (61.76%) which then was reflected 10 years
later in the Year 11 study with the highest number of KUs in the 40-49, n = 85
(48.85%) age group. All age ranges showed an increase with the exception of the 1729 group which went from Year 1 n=11, to Year 11 n=5 (Refer Table 10).
Table 10
Kava User crosstabulated by Age
Age
Year 1
Year 11
No
Yes
Total
No
Yes
Total
285
11
296
10
5
15
96.28
3.72
100
66.67
33.33
100
321
42
363
199
54
253
88.43
11.57
100
78.66
21.34
100
74
11
85
237
85
322
87.06
12.94
100
73.60
26.40
100
50-59
16
4
20
70
25
95
%
80
20
100
73.68
26.32
100
60+
1
0
1
23
5
28
%
100
0
100
82.14
17.86
100
Total n
697
68
765
539
174
713
17-29
%
30-39
%
40-49
%
The pattern emerging from the data collection in this table shows a continuation of
Kava consumption across the lifespan displaying the older population of participants
increasing with time.
Psychological distress and kava usage
A Pearson’s Chi Square test was conducted to ascertain if there were associations
between kava usage and psychological distress (Refer Table 11).
29 Table 11
Kava User crosstabulated with Psychological Distress
Year 1
Year 11
No
Yes
Total
No
Yes
Total
680
67
747
478
156
634
%
91
9.0
100
75.4
24.6
100
Symptomatic
17
1
18
41
11
52
%
94.4
5.6
100
78.8
21.2
100
Total
697
68
765
519
167
686
Non-Symptomatic
In Year 1 symptomatic KUs were n=1 and in Year 11 n=11. There was no significant
association between kava usage and psychological distress as Year 1 p= .615, and in
Year 11, p= .577.
Acculturation and kava usage
A Pearson’s Chi Square test was performed to ascertain significance between
acculturation and kava usage. In Year 1 and Year 11 the highest amount of KUs
identified in Separation. Year 1 n=48 (72.7%) and in Year 11 n=65 (39.6%). In year
1 and year 11 p < .001 showing statistical significance of associations between
acculturation and kava usage (Refer Table 12).
30 KU and Acculturation
Table 12
Acculturation
Year 1
Year 11
Not KU
KU
Total
Not KU
KU
Total
Assimilation
243
8
251
190
29
219
% of Assimilation
96.8
3.2
100
86.8
13.2
100
% of KU
35.1
12.1
33.1
37.1
17.7
32.4
Separation
253
48
301
132
65
197
% of Separation
84.1
15.9
100
67.0
33.0
100
% of KU
36.5
72.7
39.7
25.8
39.6
29.1
72
2
74
64
23
87
% of Integration
97.3
2.7
100
73.6
26.4
100
% of KU
10.4
3.0
9.8
12.5
14.0
12.9
Marginalisation
124
08
132
126
47
173
% of Marginalisation
93.9
6.1
100
72.8
27.2
100
% of KU
17.9
12.1
17.4
24.6
28.7
25.6
Total
692
66
758
512
164
676
Integration
In Year 1, Separation was the most identified category of acculturation for both KU
and non-KU. In Year 11, Separation remains the highest for KU followed by
Marginalisation whereas for non-KU, Separation decreases and Assimilation
increases to be the most predominant category for non-KU.
Alcohol and kava usage
When conducting cross tabulations between alcohol and kava consumption, the
results showed p = 0.97 at Year 1 and p = 0.11 at Year 11, thus there is no significant
association between kava consumption and alcohol use (Refer Table 13).
31 Table 13
Kava User crosstabulated with Alcohol User
Does drink alcohol
Year 1
Year 11
No
Yes
Total
No
Yes
Total
No
373
43
416
220
72
292
Yes
325
25
350
319
102
421
Total
698
68
766
539
174
713
In Year 1 the majority of participants did not drink alcohol however, in Year 11 there
are increases in both alcohol consumption with over half now consuming alcohol, and
Kava consumption increased fourfold.
3.3.2 Problematic Kava Usage
Suggest KU cut down on kava consumption
An area that was one of the main motivators for the present study was the
psychosocial impact Kava usage may have on families and significant others.
Significant others are those who have a regular involvement with the KU and have
such a relationship that they feel it appropriate to address excessive kava consumption
with the KU. The following table identifies an area where someone familiar with the
KU may have raised concerns over their usage and suggested the KU cut down their
kava consumption. In Year 1 only n=8 (11.6%) of KUs had a significant person in
their life suggest that they cut down on their kava usage however, in Year 11 that
number more than doubled with over a quarter expressing concern n=46 (26.4%)
(Refer Table 14).
Table 14
Should cut down
KU should cut down on Kava Consumption
Year 1
Year 11
n
%
n
%
No
61
88.4
128
73.6
Yes
8
11.6
46
26.4
69
100
174
100
Total
32 When a significant other has suggested that the KU cut down on Kava consumption, it
is then termed ‘Problematic KU’. This table identifies that of the total 174 KUs, 46
are regarded as problematic Kava users.
Problematic KU and Ethnicity
With patterns starting to emerge particularly with over a quarter of KUs having
concern shown over their usage, statistical analysis was conducted to examine if a
KUs ethnicity had a significant association with kava usage and particularly
problematic kava usage. Kava usage was problematic for n=8 (11.5%) of KUs in Year
1 however, that number increased to n=46(26.44%), with n=37(80.4%) of problematic
KUs identifying as Tongan (Refer Table 15).
Table 15
Problematic KU and Ethnicity
Suggest cut down KU
Year 1
Year 11
No
Yes
Total
No
Yes
Total
14
3
17
41
6
47
% of Samoan
82.4
17.6
100
87.2
12.8
100
% of KU
23.0
37.5
24.6
32.0
13.0
27.0
45
4
49
76
37
113
% of Tongan
91.8
8.2
100
67.3
32.7
100
% of KU
73.8
50.0
71.0
59.4
80.4
64.9
0
0
0
3
2
5
60.0
40.0
100
2.3
4.3
2.9
Samoan
Tongan
Cook Island
% of Cook Island
% of KU
Other Pacific
2
1
3
8
1
9
66.7
33.3
100
88.9
11.1
100
% of KU
3.3
12.5
4.3
6.3
2.2
5.2
Total
61
8
69
128
46
174
100
100
100
100
100
100
% of Other Pacific
% of KU
All ethnicities are represented in the problematic KU area however, the major portion
of that is Tongan (80%) followed distantly by Samoan (13%).
33 Problematic KU and Age
With previous qualitative studies conducted on specific KU age groups, evidence was
sought to see if age was a factor that influenced kava consumption. Year 1 showed
n=1 in age groups 17-29 and 40-49, with the majority of concern shown in the 30-39
age group with n=6. Year 11 shows a significant increase in concern shown across
various age groups with the greater number of concern shown in the 40-49 age group
with n=27. The 30-39 age group has increased with n=11, and concerns are now being
expressed in all age ranges (Refer Table 16).
Table 16
Problematic KU and Age
Age
Year 1
Year 11
No
Yes
Total
No
Yes
Total
11
1
12
4
1
5
91.67
8.33
100
80
20
100
36
6
42
42
11
53
85.71
14.29
100
79.25
20.75
100
10
1
11
59
27
86
90.91
9.09
100
68.6
31.4
100
4
0
4
19
5
24
100
0
100
79.17
20.83
100
60+
0
0
0
3
1
4
%
0
0
100
75.0
25.0
100
61
8
69
127
45
172
88.41
11.5
100
73.84
26.16
100
17-29
%
30-39
%
40-49
%
50-59
%
Total n
%
As groups age, so does the increase in problematic KU. In Year 1 there were 6
participants identified as problematic KUs in the 30-39 age group however, 10 years
later the 40-49 age group now has 27 problematic KU participants. All groups are
showing an increase as they age.
34 Problematic KU and GHQ-12
Problematic kava usage and psychological distress was explored to gain an insight
into the psychological impact of kava and determine any significant associations.
Results show that overall problematic KUs score less than other KUs in relation to
symptomatic issues in both years although generally, all KUs show little symptomatic
issues with only n=1 in Year 1 (p=.715) and n=11 in Year 11 (p=.325). Thus there is
no significant correlation between kava usage, problematic kava usage and
psychological wellbeing (Refer Table 17).
Table 17
Psychological
Problematic KU and GHQ-12
No
Yes
Total
No
Yes
Total
60
8
68
115
40
155
88.2
11.8
100
74.2
25.8
100
1
0
1
6
4
10
100
0
100
60.0
40.0
100
61
8
69
121
44
165
88.4
11.6
100
73.3
26.7
100
Wellbeing
Non Symptomatic
%
Symptomatic
%
Total
%
In both years there is little significance between problematic KU and psychological
distress. Although there is an increase in 4 participants being symptomatic in Year 11
this is a minor increase.
Problematic Kava Usage and Acculturation
Problematic KU was crosstabulated against acculturation in the fourfold categories
and bivariate analysis conducted to establish if there was an association between the
two. This was tested with a Pearson’s Chi-Squared test. Year 1 did not show any
significant association between problematic kava usage and acculturation, although
this may be due to the sample being smaller. In Year 11 there were significant
associations (p=.009) between KU and separation (Refer Table 18).
35 Table 18
Problematic Kava Usages and Acculturation
Suggest Cut down KU
No
Yes
Total
No
Yes
Total
7
2
10
25
2
27
77.8
22.2
100
92.6
7.4
100
43
5
48
40
26
66
89.6
10.4
100
60.6
39.4
100
2
0
2
19
4
23
100
0
100
82.6
17.4
100
7
1
8
35
12
47
87.5
12.5
100
74.5
25.5
100
59
8
68
119
44
163
88.1
11.9
100
73.0
27.0
100
Assimilation
%
Separation
%
Integration
%
Marginalisation
%
Total
%
In both Year 1 and Year 11 there were little changes in relation to Assimilation and
Integration however, there were significant increases in both Separation and
Marginalisation. Over half of the Problematic KUs in Year 11 identified as
Separationalists.
36 CHAPTER 4: DISCUSSIONS
4.1 Summary of Main Results
For many Pacific, kava symbolizes more than being a beverage to consume. It brings
cultural identity, loyalty, friendship, and unity. Kava ceremonies are steeped in
traditions, cultural etiquette, and are a way to communicate things of the past, present,
and future. For many Pacific, it is a fundamental centerpiece on which is based
cultural ideology (Smith, 2011). As time has passed, for some Pacific so has the
traditional usage of kava as Western influences and global accessibility impact on the
way in which kava is viewed. It has become a valuable commodity for some nations
who benefit from the export of kava products to other countries (Lindstrom, 2009).
Although some countries have banned or limited the importation of kava, others are
still supporting its importation albeit a little apprehensive of the side effects hence the
FDA issuing a warning around kava usage and the WHO recommending further
research be conducted on aqueous products (Lindstrom, 2009). Despite any negativity
surrounding kava usage, Pacific are still consuming it in large amounts and as this
study has identified, this appears to be on the increase for Pacific living in South
Auckland.
Increased consumption may be relevant when relating it to the need for Pacific to hold
on to a cultural practice or learn of traditional beliefs and values that have huge
cultural significance. The connections made to ancestral links and ancient customary
practices are recognized within the kava ceremony. A kava ceremony provides a place
for learning within ones own cultural realm, and also provides opportunities for others
to gain an understanding of a specific cultural ritual (Smith, 2011). A celebration,
special occasion, or significant event is not complete without the kava ceremony
(Victoria University, 2013). Holding onto one’s culture may prove difficult at times
with issues arising from immigration and also for first generation children whose
parent’s may be adjusting to societal changes and influences.
Adjusting to a new culture and all that it encompasses appears to have an effect on the
KUs. Borrows et al. (2011) emphasise the need to acknowledge the multiple factors
37 that impact on a migrant including the society they have left behind, the migration
process, and the adjustment needed to settle into a new society. The present study
explored John Berry and colleague’s four-fold model of acculturation and kava usage.
The purpose was to identify if there were any significant correlations between kava
usage and assimilation, separation, integration, and marginalisation. KU was crosstabulated against acculturation in the four categories. The association was tested with
a chi-squared test and significant variations were found at both time points.
In the year 1 result for KUs, at 72.7% separation was a larger factor than the other
categories with assimilation only being at 13.2%. This shows a large number of KUs
identified with their culture of origin and there were few assimilating with the New
Zealand culture. However, in the year 11 results separation decreases to 39.6% which
may support the evidence suggesting that holding onto one’s original culture may
help individuals adapt better into the new culture. Results show increases in all other
areas with marginalization being the second most identified with. It is possible that
some of those who no longer identify as separationists may now not identify with
either culture. Assimilation has increased with 17.7% of KUs adapting to the New
Zealand way of life and 14% integrating both cultures. Studies have shown that of all
four categories, integration of both cultures is the least stressful (Jackson, 2006).
For some Pacific families in New Zealand, the culture behind kava ceremonies and
kava consumption may be a dominating factor more so than for other ethnicities. The
largest number of participants identify as Samoan, which is reflective of the societal
norm in South Auckland. However, the largest numbers of KUs registering 113 out of
a total of 176 KUs are Tongan. This may be due to kava ceremonies being a pivotal
aspect of Tongan culture and the desire for some Tongans living in New Zealand to
hold onto their culture of origin.
Fortunately for Pacific in South Auckland, kava is consumed in an aqueous solution
and therefore not subjected to the complications that may arise with the extraction
process. With varying kava cultivars, product quality, portion of plants, and chemicals
used in the extraction process, there is a risk that the final product does not have the
same beneficial effects as the aqueous form consumed by Pacific (Whitton et al.,
2003). As past research has honed in on the adverse effects of kava in non-aqueous
38 formulations on the physiological dysfunctions, additional research is providing
insight into the adverse psychosocial effects kava is having on KUs and significant
others in their lives. The results suggest that 26.4 of KUs have had significant others
raise concerns over their kava usage. This result is consistent with the Nosa and
Ofanoa (2009) qualitative study that found of the 12 men interviewed, 22% of KUs
stated that their kava usage had a negative impact on their families.
4.2 Interpretations of Results
For some Pacific living in South Auckland, adjusting to the New Zealand way of life
has at times proved difficult. As some have tried to stay connected to their culture of
origin this has included participating in kava ceremonies and kava consumption.
Research has shown that for Pacific there is no physiological long-term effect as once
kava consumption is stopped, any biological dysfunction may be reversed. However,
there is insufficient research done especially in the Pacific Island nations to confirm
or deny this. This lack of evidence is therefore not able to provide facts or truth about
the effects of kava. There is little empirical data available and, apart from the study
done in Vanuatu Hospital, there are no specific studies done in the hospital setting
assessing data pertaining to kava consumption and its possible adverse effects on
Pacific. Therefore, it is possible that Pacific may experience serious health
implications due to kava usage however, with little evidence available this is not able
to be determined.
What is clear in the results is that kava consumption is on the increase across all
Pacific cultures living in South Auckland. Moreover, there is noticeable substantial
growth within the Tongan community with over half of the participants currently
consuming kava. This is a significant increase from the Year 1 result when
approximately quarter were KUs. With a large proportion of KUs, it is logical that
there may be some adverse effects experienced by Tongan KUs. The results of this
study verify that of all KU participants, over 80% of problematic KUs are Tongan.
This study suggests that within the Tongan community, there are 37 KUs and families
that are experiencing negative effects from kava usage. Within the realms of this
study it is unable to provide reasons as to why, for these participants kava usage has
39 become problematic however, there is evidence that this may be a result of
acculturation factors.
The acculturation findings show most problematic KUs identify mostly in the
separation facet of the Berry’s fourfold model of acculturation. Separation entails the
problematic KU holding firm to their culture of origin, which may make adapting to
the New Zealand societal ideology difficult. Attendance of kava sessions may be a
source of identity and by continued association within the kava domain; this cultural
identity will remain dominant through cultural reinforcement (Schluter, Tautolo, &
Paterson, 2011). It seems likely that fellow kava consumers would be of the same
ethnicity especially as the results confirm that most kava consumption is experienced
with friends, family and community groups. For some Pacific, kava is an innate part
of their culture and when seeking identity within a new cultural context, language and
other barriers may seem daunting and it may be easier to hold firmly to the culture
that is already well known to the KU.
The results of this study have identified patterns of kava usage that show increase in
consumption, frequency, issues surrounding acculturation into New Zealand society,
and a significant increase in the emerging patterns involving problematic kava usage.
Although the Tongan participants are highlighted due to higher numbers of KUs, it is
still important to acknowledge that kava usage on the whole is increasing and as
numbers increase so will the negative impact on significant others. As evidence show
there is no or little adverse biological effects nevertheless, this study along with
research conducted by Kava (2001) and, Ofanoa and Nosa (2009) acknowledge that
there are negative psychosocial effects that may lead to the breakdown of Pacific
families.
Kava has a pivotal role in Pacific culture, but family is the essence and life force of
the Pacific people. If there is a threat to the breakdown of family dynamics and
relationships, then the wider Pacific and New Zealand community may feel the
effects. The people of Fiji experienced the damage kava usage can do from many
facets including financial strain on families, employee unreliability, strained family
relations, decreased crop production for exports, and police involvement (Kava 2001).
The New Caledonia community felt the affects of kava usage in their young people
40 and research on Kanaks has shown a strong association between kava usage and
suicidal behavior (Vignier, Lert, Salomon & Hamelin, 2011). In New Zealand we are
seeing patterns forming and have the opportunity to act on this swiftly if research
continues and interventions are developed and implemented.
4.3 Limitations and Future Research
The use of a questionnaire and interview to collect data has an element of risk in
relation to participant honesty with their answers. Social desirability may be a factor
and entails a participant adapting their answers in order to be seen in a more positive
light or socially acceptable manner (Epinosa & van de Vijver, 2014). When
interviewers are asking questions around behavior that may be deemed problematic, it
is possible participants may not want their behavior to be classified as problematic
and may choose to adjust their kava intake and frequency. The PIF study screens for
discrepancies in the answering of questions and is able to identify if there are issues
that may affect the validity of the study. To counter issues such as social desirability,
when possible, other male Pacific of same ethnicity so as to minimize causation for
social desirability interviewed KUs.
As AUDIT is a screening measure for alcohol use, it does not allow for exploration
into what may explain problematic behavior. AUDIT is adequate to gauge amount,
and frequency however, the difference in problematic alcohol and kava quantity
consumption are different. 10 or more glasses of beer in comparison to 10 or more
shells of Kava are not comparable. Research into kava consumption and usage
specifically to screen for problematic kava usage would be beneficial to hospitals,
social agencies, and those dealing with the negative effects of kava consumption.
Research into a Kava Usage Inventory (KUI) development would be advantageous for
those working in the psychosocial realms. The ability to screen for problematic kava
usage may be useful for both social agencies and also for the KU themselves. KUs
may not realize the effect their kava consumption and behavior is having on
significant others and therefore may not be aware of the need for an intervention.
41 Chanwai (2000) also suggests that kava intoxication-attention needs to be given in
educating kava consumers about the importance of balanced nutrition, the adverse
effects of kava consumption, and the modification of behavior to decrease the amount
of kava consumed. Research in hospital admissions with those suspected of kava
intoxication would be valuable in gathering accurate data on whether kava is an issue
for Pacific and if so, what they are.
The use of the GEQ in the PIF study provides comprehensive data when assessing a
participant’s acculturative experience from multiple domains, has proven to be
reliable and valid in most samples, and is easily modified for diverse cultures.
However, although assessing information on multiple domains, there are significant
areas not assessed, there is limited psychometric data for specific groups, and
emphasis is placed on the measuring of behavior and practices as opposed to values
and beliefs which would skew the results for Pacific if the GEQ was utilized
unmodified.
4.4 Conclusions
Overall, gathering data from the PIF study was invaluable and provides the first
longitudinal data on kava consumption in New Zealand. Although this data is
collected from participants living in New Zealand, the information gathered, and the
participant’s cultural links are not restricted to limitations within a New Zealand
societal context and would therefore be beneficial to most populations globally where
kava is consumed. There is currently insufficient information in regards to kava
consumption and the effects this has on families, therefore future research in this area
would be highly recommended. Strong recommendations would be to research and
develop a kava usage inventory to screen for problematic kava usage. This may help
to identify who kava is problematic for, how it is affecting the KU and others, and
influence the formulation of an intervention when needed. This may then guide future
research in New Zealand on the psychosocial impacts of kava usage.
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48 APPENDIX A
Kava Questions
B56. Over the LAST 12 MONTHS how often did you USUALLY drink KAVA?
Never (Skip to B60)
1-2 times a year
About once a month
(0)
(1)
(2)
About once a week
2-3 times a week
Daily
(3)
(4)
(5)
B57. How many drinks containing KAVA did you have on typical day when you
were drinking?
1 or 2
3 or 4
5 or 6
(0)
(1)
(2)
7 to 9
10 or more
(3)
(4)
B58. Who do you usually drink KAVA with?
1.
2.
3.
4.
5.
No
0
0
0
0
0
Alone
Family
Friends
Community groups
Other
Yes
1
1
1
1
1
B59. Has your partner, a relative, friend, doctor or other health worker been
concerned about your KAVA drinking or suggested that you should cut down?
No
(0)
Yes, but not in the last year
(1)
Yes, during the last year
(2)
49 APPENDIX B
GEQ-12 Questionnaire
Pacific Islands (PIACCULT) and New Zealand (NZACCULT) Acculturation Scales.
The PIACCULT (Pacific orientation)
[a] I was brought up the Pacific way
I am familiar with Pacific practices and customs
can understand a Pacific language well
have several Pacific friends
Most of my friends speak a Pacific language
participate in Pacific sports and recreation
speak a Pacific language
have contact with Pacific families and relatives
Pacific food
a traditional Pacific healer when I have an illness
church that is mostly attended by Pacific people
[b]
[c] I
[d] I
[e]
[f] I
[g] I
[h] I
[i] I eat
[j] I visit
[k] I go to a
The NZACCULT (New Zealand orientation)
[a] I was brought up the New Zealand way
[b] I am familiar with New Zealand practices and customs
[c] I can understand English well
[d] I have several non Pacific friends
[e] Most of my friends speak English
[f] I participate in New Zealand sports and recreation
[g] I speak English
[h] I have contact with non-Pacific families and relatives
[i] I eat non-Pacific food
[j] I visit western-trained doctors when I have an illness
[k] I go to a church that is mostly attended by non-Pacific people
The PIACCULT instrument was elicited first. The interviewer says, “I will
read a list of statements. Please tell me how much you agree or disagree with
each one using the following scale
(1)
(2)
(3)
(4)
(5)
Strongly disagree
Disagree
Neither disagree or agree
Agree
Strongly agree”.
A card showing these response options is given to the participant and questions
[a] to [e] are then read aloud and responses recorded. Next the inter- view says,
50 “Now using this card which has response options
(1)
(2)
(3)
(4)
(5)
Not at all
A little
Somewhat
Quite a lot
A lot,
Please tell me how much or how often you do the following things.” A card
showing these response options is given to the participant and questions [f] to
[k] are then read aloud and responses recorded. The process is then repeated for
the NZACCULT instrument.
51 APPENDIX C
GHQ-12 Questionnaire (General Health Questionnaire)
We want to know how your health has been in general over the last few weeks. Please read
the questions below and each of the four possible answers. Circle the response that best
applies to you. Thank you for answering all the questions. Have you recently:
1. Been able to concentrate on what you’re doing?
better than usual (0) same as usual (1)
less than usual (2)
much less than usual (3)
2. lost much sleep over worry?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
3. felt that you are playing a useful part in things?
more so than usual (0) same as usual (1)
less so than usual (2) much less than usual (3)
4. felt capable of making decisions about things?
more so than usual (0) same as usual (1) less so than usual (2)
much less than usual (3)
5. felt constantly under strain?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
6. felt you couldn’t overcome your difficulties?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
7. been able to enjoy your normal day to day activities?
more so than usual (0) same as usual (1) less so than usual (2)
much less than usual (3)
8. been able to face up to your problems?
more so than usual (0) same as usual (1) less so than usual (2)
much less than usual (3)
9. been feeling unhappy or depressed?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
10. been losing confidence in yourself?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
11. been thinking of yourself as a worthless person?
not at all (0) no more than usual (1) rather more than usual (2) much more than usual (3)
12. been feeling reasonably happy, all things considered?
more so than usual (0) same as usual (1)
less so than usual (2)
much less than usual (3)
52 General Health Questionnaire Scoring
Scoring – Likert Scale 0, 1, 2, 3 from left to right.
12 items, 0 to 3 each item
Score range 0 to 36.
Scores vary by study population. Scores about 11-12 typical.
Score >15 evidence of distress
Score >20 suggests severe problems and psychological distress
53