El alcohol en la ciudad de Madridaproximación por métodos mixtos (observación social sistemática y fotovoz)

Resum

Alcohol is the most widely consumed psychoactive substance in the world and its use is associated with more than 200 diseases. In recent years, there has been a growing interest in understanding the relationship between the urban context (physical and social) in which we live, work and carry out other daily activities and alcohol consumption. The main objective of this thesis is to comprehensively characterize the urban alcohol environment using different methodologies in the city of Madrid. To conduct this work the following specific objectives were defined. 1. To characterize the availability and promotion of alcohol in alcohol outlets and compare its distribution according to the typology of the outlets and the socioeconomic conditions of the area. 2. To describe the perceived alcohol environment by residents in two districts of the city of Madrid using a Participatory Action Research methodology, the Photovoice. 3. To describe and compare, in terms of availability, promotion and signs of alcohol consumption, the results obtained through Photovoice and those captured by Systematic Social Observation, in two areas of different economic status 4. To describe if there are changes in the perceptions of the alcohol urban environment among residents after their participation in the Photovoice. 5. To use geovisualisation techniques, based on tools contained in Geographic Information Systems, to describe acceptability and other attitudes in relation to alcohol exposure in the urban environment in Madrid. Each of the afore mentioned objectives were developed in different research articles. To respond to objective 1, research article 1 was proposed. In this study, 42 census sections were selected in the city of Madrid, representative by socio-economic level. During May-November 2016 we characterized the availability of on-premise alcohol outlets (e.g. supermarkets, convenience stores, etc.) and off-premise alcohol outlets (e.g. bars, restaurants, etc.) and the promotion of alcohol associated to these premises characterized using the OHCITIES instrument (a validated tool previously used by the research group). The results showed a higher availability of alcohol and alcohol promotion associated with alcohol outlets, especially in bars. It was also found that, in areas of higher socio-economic status, the presence of on-premise alcohol outlets was higher than in vulnerable areas. Future studies should consider these differences when analysing the effects of the alcohol environment on drinking patterns and in designing new interventions to prevent alcohol consumption. For the development of objectives 2, 3, and 4, the Photovoice methodology was applied. Photovoice is a Participatory Action Research methodology that aims to carry out a critical dialogue around a problem or issue of interest using photography. In this case, the topic of interest was the presence of alcohol in their neighborhood. Two districts of the city of Madrid were selected, representing two different socio-economic contexts. Chamberí was chosen as the district representing the high socio-economic level (HSE level) and Villaverde as the low socio-economic level (LSE level). For each of the objectives set out, different strategies of analysis were proposed in research articles 2, 3 and 4. Article 2 described the characterization of the alcohol environment as perceived by the residents exposed using Photovoice. Participants grouped the main relevant elements of their environment into 33 categories. These categories were regrouped by the research team into 7 common general areas that addressed: 1) Alcohol´s socializing role; 2) Diversity in the price & establishments in which to buy or consume alcohol; 3) Profitability of the alcohol business; 4) Advertising; 5) Alcohol consumption and minors; 6) Negative effects of alcohol consumption in public spaces; and 7) Different social groups display different drinking patterns. In addition, each district identified specific categories related with their environments. In the district with LSE level, the association between alcohol and the population's diet was identified through the category "Alcohol and nutrition". Meanwhile, HSE-level district developed the relevance of the touristic nature of their environment, with huge option of leisure in the category "Chamberí is the place to be". Article 3 compared qualitative and quantitative data of the alcohol environment. We obtained qualitative measures using Photovoice and quantitative measures through social systematic observation. Data were integrated using triangulation. The grade of integration was classified as agreement, partial agreement, dissonance or muted. The results related to alcohol availability and signs of its consumption showed high agreement. Availability was high in both areas, which was recognized by residents. Residents of the HSE-level district discussed fewer signs of alcohol consumption, whilst those in the LSE-level district reported extensive signs of consumption. Such observations agreed with the objective measures. There were dissonances between the approaches for alcohol promotion. Although the alcohol promotion was higher in HID according to the objective measures, it was deeply discussed by the residents of LSE-level district. Article 4 described the changes in perceptions of the alcohol environment among the participants of Photovoice during the sessions. Changes in perceptions of the alcohol environment were observed in all groups over the project. The process of change varied by districts' socio-economic characteristics and gender. Greater changes in perceptions of the alcohol environment were observed in HSE-level district, especially among women, as the participants had a much more positive initial view of their alcohol environment. Participants from LSE level district showed a more critical perception of the alcohol environment from the beginning of the study, and this broadened and intensified over the course of the sessions. Changes in perceptions also varied by thematic categories, including some categories that were discussed from the start (e.g. socialising and alcohol consumption) and categories that only emerged in later sessions (e.g. alcohol advertising). Finally, article 5 is a study with the aim to utilize geovisualisation-based methodology to assess attitudes towards different levels of alcohol exposure in urban environment. We selected a typical downtown location, Lavapiés Square in Madrid, Spain, to conduct our study. First, we designed and created realistic 3D models simulating three different urban scenes with varying degrees of exposure to alcohol in the environment. Second, we used a survey on 159 adults to explore the level of acceptance of, attitudes towards, and perceptions of alcohol exposure in each scene. Participants reported a higher level of comfort in the scene with null alcohol exposure compared with the other scenes. Acceptance towards alcohol exposure decreased as the level of alcohol elements increased in the scenes. Acceptance also decreased when children were present in the scenes. This study demonstrated that geovisualization tools provide a useful and wellsuited approach to analyze perceptions of the alcohol environment. The results obtained highlighted the role of the presence of minors in urban environments with high levels of alcohol exposure in the increasing risk perception. This doctoral thesis provides a very comprehensive description of the alcohol environment in the city of Madrid and the experience of their exposed population. Thanks to the combination of different methodologies, we have identified alcohol related elements highly accepted by the population and the different strategies promoted by the alcohol industry to reduce risk perception of its consumption. Therefore, the results obtained promote different conclusions. First, they are useful to identify future challenges in research on the urban alcohol environment and its relationship with alcohol consumption. Secondly, they offer very interesting keys that could be very helpful when designing strategies and interventions to prevent alcohol consumption and improve population health.