The majority of adults are in the workforce and with the increasing workload, employees do not have much choice than to spend a substantial proportion of their time at their place of work . Studies have reported a strong association between stress at the workplace and elevated levels of alcohol consumption . Alcohol, especially heavy drinking, represents a serious challenge for a number of work sectors and occupations  . Globally, heavy drinking is more common in younger than older employees, and more among male than female employees . This conduct has been recognized to have a major health risk in terms of disability and the effect on work productivity is enormous  .
Alcohol abuse has adverse effect on workplace outcomes resulting in absenteeism, presenteeism, work accidents and injury, turnover intentions, work squabbles, sleeping on the job among other losses . These issues have been of great concern to a number of employers facing such challenges in their organisations. Employees with heavy drinking habits are challenged in some ways especially on their performance at work. The aftermath of drinking can linger at least 24 hours which may impair employees’ productivity . While heavy drinkers may be qualified individuals with expertise, they may just be present at work but unable to work, a common cause of presenteeism . Stigmatization, isolation and rejection are some forms of emotional struggle that employees with heavy drinking face at their workplace  . This means in addition to “fighting” their disease addiction, they also fight stigma, isolation and rejection which increase their stress levels and decrease their productivity  .
These stigmatizing attitudes result in discrimination at the workplace, such as the unfair denial of employment opportunities, as well as restricted access to services, health insurance or housing . Most employees are unable to discuss their drinking habits with their employers for fear of being discriminated against  . However, if the employer perceives that an employee is exhibiting such tendencies, it is required that the person discloses their status irrespective of the outcome. Based on this, clinical practitioners and researchers are of the opinion that employers are in a powerful position to stamp out stigma tied toAUD in organisations . Instead, some employers are of the view that such individuals are inept, need extreme supervision, lack understanding and enthusiasm for work, are violent, erratic, are unable to meet work targets, and are more likely to absent themselves from work  
Even though most organisations have work policies and legislations for workers with heavy drinking habits, a few studies have shown that employees with such habits for instance face significant barriers in their place of work. This is because most employers are unaware and lack understanding of what constitutes alcohol or substance use disorder. In another study, the researchers reported that even after weeks, months and sometimes years, when employees have gone off drinking they are perceived to have an aberrant behaviour, weak, lazy and unproductive . Employees with drinking habits are socially marginalized and have to cope with negative comments from workmates and consequently made to return to positions of reduced responsibility  . A growing number of research have shown that employers are more likely to dismiss employees when they find out they are addicted to alcohol, especially in cases where their status was not disclosed during the hiring process  and the tendency of such employees being dismissed when there is a downsizing is high .
Although the workplace is a great source of distress to many employees, research has shown that the workplace offers many benefits as a setting for the prevention of AUD . The workplace can be an important and effective place to address AUD by establishing or promoting programs or policies to address the challenge  . There have been organizational interventions to identify and manage drug problems among employees. The most common is the Employee Assistance Programs (EAPs). EAP has been used as a strategy to enhance the functioning, loyalty and performance in organizations around the world . This policy is known to assist employers by reducing the negative impact of alcoholism in the workplace, while reducing organisational cost and improving productivity. AUD treatment also improves an individual’s functioning leading to increased productivity at work and maximize recovery . Through EAPs, employers are trained on how to manage employees with drinking habits with evidence and describe what will be required to bring job performance to an ultimate level .
The use of alcohol in Ghana is strongly linked to customs and cultural practices  . In recent times there has been records of alcohol use among the youth, women and children in particular . This new trend is attributed to political, economic and cultural changes. For instance the liberal advertising, marketing and distribution of alcohol in Ghana has accounted for the large scale production and its consumption. Moreover, manufacturers of alcohol make huge sums of money from production, marketing and sales of alcohol in this part of the world. With the influx of cultures, alcoholic beverages from the western countries have become readily available for both the young and old, male and female and even in the workplace on a commercial basis . The workplace is increasingly becoming a risk factor for alcoholism and harmful alcohol use . While personal factors can act as a contributing factor to this menace, organizational causes are equally responsible for employees’ alcohol use .
In Ghana, organizational factors such as work structure, work culture and psychosocial constraints have been identified as triggers to alcohol use in the workplace . It has been shown that employees who were exposed to alcohol were at risk of absenting from work and were less efficient in carrying out responsibilities . In a similar study, it was reported that the presence of alcohol at the workplace has a causal relationship with job stress and job withdrawal, health problems and it affects productivity . The workplace can contribute positively to a person’s mental health or may worsen an existing problem, and or may lead to the decline of a person’s mental wellbeing. Organizational, as well as personal factors, contribute to AUD in some employees .
The failure to prevent, recognize and treat drinking problems in the workplace is said to affect employees’ productivity. Only a small proportion of people with alcohol problems are hired or allowed to work when they disclose their challenges to their employers . In recent times there have been a growing number of educational programs, training workshops and even online resources that aim to change perception and attitudes about employers towards their staff with alcohol use problems . Notable among these plans is the creation of employment assistance programs (EAPs) to address and provide assistance to such employees. In spite of all these efforts by mental health professionals to sensitize employers and with the introduction of EAPs in some organisaitons, there have been reports of prejudice, stereotypes and discrimination against heavy drinkers in organisations. There have been little alteration in how employers perceive staff with such problems, even in originations with these programs  .
Similarly, there has been little changes in employers’ attitude toward employing and accepting staff with AUD. Research evidence has shown that human resource (HR) managers of small-and-medium sized organizations are reluctant in taking on staff with mental illnesses as they do not have the needed resources such as a department of human resource management or trained professionals (EAPs) to handle the mental health needs of staff . Some employers have argued that they do not hire such persons because they do not have time dedicated to support staff who are unable to meet targets because of their problems . A number of employers lack access to their employee mental wellbeing, do not have policies and legislations or support systems in their workplace to address the needs of staff with drinking problems. As noted by many employers, stereotypes, prejudice and discrimination towards alcohol addiction remain a major challenge at work. Yet, most employers are less concerned about the mental well-being of their staff, they are only preoccupied with the numbers (profit maximization). Despite the evidence of the negative impact of alcohol on workplace performance, surprisingly, there are a few studies that have looked at perceptions and attitudes of employers towards employees with AUD. Similarly, in most organisations, there are no clear cut policies and rules on implementation and preventive strategies to reduce the harm caused by alcohol. Even where there are policies, such as Ghana Health Service, it tends to be punitive instead of corrective or preventive hence the need for this study. The study, among other things seeks to explore the perception and attitude of employers toward employees with AUD, as well as examine the effects of the implementation of EAPs in organisations.
2. Research Methodology
2.1. Research Design and Method
The study employed the cross sectional research design to gather and analyze data. To infer outcomes, the study adopted the qualitative research approach to provide rich and in-depth information of a multifaceted occurrence . Similarly, qualitative approach is thought to be exploratory with regards to its method of collecting data, analyzing the information gathered and making meaning of the outcomes  . Again, it gives the researcher the leeway to probe the interviewees and further interpret the meanings given to the phenomenon.
To understand the perceived attitudes of HR managers towards employees with AUD in their organisations, the researchers purposively sampled and interviewed 10 HR managers from 5 private (labelled R1-R5) hospitals with not less than 100 employees and 5 public (labelled S1 - S5) hospitals, government hospitals with at least 200 employees in the Accra Metropolis. This included HR managers of the following hospitals; Accra Psychiatric Hospital, Weija Hospital, La Hospital, Legon Hospital, Ridge Hospital, Mamobi Polyclinic, Cocoa Clinic, Lekma Hospital, Greater Accra Regional Hospital and the Trust Hospital. Government run hospitals generally tend to employ far more than the private facilities with similar patient load as they do not pay for overtime while the private ones keep same staff and pay for overtime. In all the facilities, the HR managers were used as a proxy for the employers. Prior to this, ethical approval was sort from the Ethics Committee of the Greater Accra Regional Health Directorate and permission was sort from the research teams of the various hospitals. Of the ten HR managers interviewed, 7 were males and 3 were females, aged between 30 and 49 years, except for one in a private hospital who was a male more than 60 years.
The interviews were conducted in the offices of the participants’ workplace with the help of two research assistants who were acquainted with the content of the study guide. Prior to this, institutional entry was sought from the research departments of the various institutions selected for this study. The interview was conducted face-to-face using an interview guide, which included open-ended questions. The structure of the guide helped the researchers to observe the participants and the conversations were also audio-taped after seeking the consent of the participants. On average, the interview lasted between 45 minutes and an hour. Extensive notes were taken during the interviews, and summaries of each interview were written right after the interview. The names of the research participants were left out to ensure confidentiality and anonymity. At the end of the data collection, all the transcripts were coded and transcribed independently by each research assistant and cross validated. To ensure content validity, summaries of the transcripts were sent to the participants to ensure that the exact meanings of their perceived attitude had been captured. Subsequently, thematic content analyses were done to generate results and to derive meanings which have been discussed in the following sections.
2.3. Analysis of Data
The data text obtained from the interviewees at their place of work was coded and transcribed verbatim as part of the analysis. All the transcripts were coded in English and thematically analyzed to generate results and derive the conclusions discussed in the next section.
3. Discussion of Findings
This aspect of the study examines the prevalence of AUD, factors that contribute to AUD at the workplace and employers’ perception of employee assistance program (EAPs). This information set a tone for a good understanding of AUD in the workplace.
3.1. Prevalence of AUD
AUD is a common condition among the working class and could be in excess of one per every 10 employees as prevalent in the general community was estimated to be 12.7% in the general US community using DSM IV . Relatively, a higher percentage than the general population is expected among the working class because AUD is a developmental disorder  beginning in the teens and generally takes some 10 years lag behind the onset of use to exhibit symptoms  by which time many people would have completed school or training and working. Many persons with AUD also die prematurely   hence the majority of persons with the condition will be within the ages of the working class.
Due to the low knowledge of AUD as a medical condition  many people tend to see it as a moral problem and will not easily disclose the existence of persons known to them with the condition. Most of the HR managers interviewed (70%) denied knowledge of employees with AUD. Some explained they could not tell while others claim it could not be ascertained even though they work in hospitals where this diagnosis is made.
I have not seen any staff drunk before. I wouldn’t actually know what constitutes it. Because of the nature of the work if anybody even takes alcohol it will be after close of work when everybody is at home, therefore it will be difficult for me to tell. On duty. R1.
Now, as I am aware, I don’t know any of my employees with such a disorder. R2.
However, the few who admitted that the staff had their condition even attempted to explain it away that such employees were either working at a very low level and so did not influence the work or that they were only temporary workers. Others did not really know the difference between regular use of alcohol and the person with AUD and will definitely be oblivious to the fact that such persons can be counterproductive. Another considered AUD to be only when the person is seen to be intoxicated with alcohol during the day, even though the alcohol withdrawal, which can manifest 12 hours after the last drink, possibly from the previous night can become a medical emergency . In fact, studies show that persons who regularly drink excess alcohol tend to be more argumentative and prone to injuries at work .
So far, we know of three and it could be irregular. Irregular in the sense that you don’t see them every day, but most times when you see them, they are drunk. So, it is irregular. R1.
Currently, I cannot pick on one, but about 8 years ago we used to have one man at the records who was an alcoholic and it affected his performance. But the people we have now have not shown any great level of that effect on them, on their performance. Probably they may go and booze, but in the morning they will come to work okay. So, when we talk about alcoholics, I do not think we have any. Myself, I drink Whiskey at home, but I come to work normal. I don’t drink to booze. R2.
Usually labourers are those seen to be drunk but maybe two to three days. Not all the time. R3.
Some employers shared:
Usually before work, but the effects will still be on during working periods. I see them in the afternoons or in the morning working day because I don’t come to work on weekends and night. R1.
Not really because they seem to reek of alcohol sometimes but you can’t perceive whether they drank it before coming to work or it was something that they drank yesterday before coming to work because they are casual workers so we don’t really know. R2.
This shows how persons with AUD at the workplace are not considered to have serious ill-health like diabetes or hypertension, which requires their employers to provide the necessary help to optimize productivity .
3.2. Factors Influencing Workplace AUD
The study found that the participants attributed factors influencing AUD to be a couple of factors which were generally classified as biological, environmental, social and psychological factors.
3.2.1. Biological Factors
Some of the HR managers believed that AUD can be inherited, this claim is in support of the biological disease model of addiction . Which asserts that individuals born with AUD have a higher propensity of getting addicted to a substance such as alcohol as compared to an individual with no genetic predisposition . According to scholars of the biological/biomedical model, alcohol use disorder can be passed on from one family member to the other hence can be traced to the family line of the individual addicted to the substance.
One respondent claimed:
I think that some people were born with this urge to drink. When you look at their family there you will realize that most of them drink. This urge tends to increase when they are surrounded by people who drink then it becomes a habit. R1.
I think its individual choices because there is no duty or no schedule which is bound to alcoholism. In as much as you could see some of the junior ranked staff drinking, sometimes you can see even people in high decision-making positions drink so I don’t think alcoholism is linked to schedules at work but rather it boils down to the individual. R2.
The study results support the findings of an earlier study which examined genetic studies of alcohol dependence in the context of the addiction cycle . Specifically, the family, twin and adoption studies demonstrate clearly that alcohol dependence and alcohol use disorders are phenotypically complex and heritable, which is estimated at approximately 50% - 60% of the total phenotypic variance. Also the study showed that the vulnerability to alcohol use disorders can be due to multiple genetic or environmental factors or their interaction which gives rise to extensive and daunting heterogeneity.
3.2.2. Environmental Factors
Some interviewees stated:
One of the factors that influence AUD are the alcohol stores that have been set up almost in every vicinity that people live in. So far as they live close to them they will find joy in drinking. So I think that it is one factor. If these stores were not there, where would they have gone to? R1.
In this hospital, probably I would say, my guys have been going to quarters here, so there’s the proximity to the selling point. There’s a place they call Chicago. So, whenever you see them coming from that direction, they’ve gone to take some shots so that’s a major factor. several years ago there was even some just at the car park in front of the hospital, they were selling alcohol there, they were stopped so now they have to walk to quarters to top up occasionally and so that’s one of the factors. R2.
The above statements from respondents indicate that people who live closer to alcohol establishments such as alcohol retail stores are prone to participate in alcoholism. Today media outlets have generated attractive adverts that attract the public. Thus people are induced to try drinking and if they enjoy it, they take no account as to whether their tolerance level to alcohol is high or low. This finding finds support in the Ecological System theory which explains how alcohol use disorder results at the workplace due to an interplay between the work environment and the employee’s internal factors. Thereby the kind of constraints and support employees receive from their employers in some way affect their behaviour on and off the job.
3.2.3. Social Factors
With social actors, participants mentioned that some employees who are addicted to alcohol, are not able to refrain from its use because of their social circles; their dire need to belong and constant participation in social functions which includes funerals, wedding ceremonies and parties. At such events these individuals overly indulge in alcohol as alcoholic beverages are usually not sold at such occasions. Since it has become a habit and they are unable to control their satiety. They end up drinking week after week as in this part of the world, social gatherings are held over the weekend. Hence, without care and control, as their tolerance level goes up, they tend to depend on alcohol whiles at work.
Most of the time when programs are organized like parties or there is a funeral, they give you alcohol to drink you cannot say that you will not take it because of your friends. You have to learn to drink it by force. And if you continue you can become addicted to it. R1.
Okay most of the people who work at the morgue and collect the refuse they are the most people seen to reek of alcohol but I can’t really tell if it’s because of those factors that they always drink alcohol. R2.
3.2.4. Psychological Factors
The sequence of the narratives showed that on an average each individual had a peculiar reason for drinking. Commonly mentioned was stress, feeling sad, hopeless and worthless about the in eventualities of life happenings and other pertinent mental health issues contributed to AUD, according to HR managers interviewed for the study. Hence, in order to leave behind their uneventful life issues some people drink with time this create some sort of dependency on alcohol in order to cope with their issues. In addition, the study showed that some unfortunate happenings in their childhood account for alcohol, taking for instance the death of a primary caregiver who would have helped them realize their goals. This disappointment if not properly managed at the initial stage can have an adverse effect on the individual later on in life.
One respondent stated:
Well, for me, I think that some people drink a lot when they are facing a problem. They think that drinking will help them to forget about the issue so they find solace in drinking which can be a serious problem. R1.
Some think that when you get boozed you forget the problems you are facing, that’s probably why they are drinking, I don’t think it’s sensible for you to drink and forget problems, you’ll never forget the problem. R2.
I think that people who went through difficult situations at a tender age start to develop drinking habits early. Since they drink to overcome their fears. And some of these children they were introduced to drinking by negative people and as they grow you realize that they become glued to alcohol use. R3.
A similar study by Keyes and colleagues  many, but not all studies have shown that exposure to adverse events in childhood, such as sexual, emotional, and physical abuse, is a risk factor for developing an AUD in adulthood. The study findings, however, are consistent with the findings of Meyers  who sampled Israeli adults with a relatively high prevalence of the ADH1B * 2 allele (47 percent either heterozygous or homozygous). A history of childhood adversity moderated the influence of ADH1B * 2 on alcohol-related phenotypes. In addition, there was a stronger effect of ADH1B * 2 on AUD severity and the maximum number of drinks consumed in a day in individuals who had a history of childhood adversity compared with those who did not.
Other studies have also shown that persons who start drinking at an early age are more likely to develop addiction later in life    . What is not clear however is, whether persons born to have addiction start drinking early or early drinking cause damage to the developing brain, particularly to the frontal lobe that develop fully in the mid-20s as opposed to the pleasure centers found in the medial temporal lobe that is developed in the teenage years . This implies that, while young people derive pleasure or euphoria from the abuse of drugs, they are unable to perceive the long term implications and consequences of their acts on their frontal lobe function.
Further, the study sought to find out if alcohol use disorders result in presenteeism, absenteeism or impaired productivity. Responses from interviewees outlined that:
Sure, sure, the number of times they fall sick affect them. Even if they are not sick the level of their strength becomes compromised, when they come to work so definitely it affects productivity. R1.
Usually these people fall sick easily and absent themselves from work. So someone has to do their work for them. R2.
From the above statements, the study disclosed that, usually people with such behaviour tend to fall ill often and absent themselves from work as too much of alcohol destroys the immune system. The result of this study is in line with the results of Buvik and colleagues as cited in  who aimed to map the frequency of alcohol related absence and inefficiency using survey data from a broad sample of employees. They also explored how alcohol use absence and presenteeism are experienced and handled using data from qualitative reviews. Further analyses revealed that alcohol absence and presenteeism result in economic and practical problems. Since most of the managers mentioned that they had to spend huge sums of money and effort on a single case of an employee who had an alcohol use problem.
In addition, this study also demonstrated that employees prone to alcohol usage demonstrated reduced productivity as the effort one may put into work is impeded. Research evidence suggests that alcohol could impair productivity. According to Andersen  its impact on the accumulation of human capital through work; the time in life when alcohol leads to ill health and premature death; and its significance in the working age population, relative to other risk factors, results in impaired health and premature death.
3.3. Attitude of Employers towards Employees with Alcohol Use Disorders
This section intended to find out the diverse form of attitude employer’s exhibit towards employees with alcohol use disorders. In line with this the study sought to know the standards these organizations have put in place to implement policies on Alcohol Use Disorders. Especially whether they have employee assistance program policies to aid employees. Some respondents asserted:
In our firm since it is a health center, counselling sessions are held in order to educate and advise us against the use of alcohol. R1.
We have a code of conduct which is spelled out clearly and every employee of the board is aware of. But sometimes they try to address it through counselling and if that fails, then they warn and query them and sometimes even dismissal letters are issued to them. R2.
No, we don’t have a separate policy for alcohol use disorder, we have a policy code of conduct, full policy it borders on everything and management have been a bit strict on it, … verbal warnings and advises, and if you fail to adhere to them, these policies are … and the punishment thereof given. R3.
Responses gathered from participants revealed that these institutions do not have a single set or a standalone policy on AUD rather it is embedded in their codes of conduct which is made known to every employee of the organization. Others also made mention of some form of assistance put in place by employers to support employees in the form of counselling programs that help employees cope with stress, mental illnesses and other related issues. None specifically mentioned Employee Assistance Programmes (EAP) clearly set aside to guide and manage the mental health needs of their workers. Although EAPs have been shown to be helpful particularly for persons with AUD  the narratives suggest that some HR managers have no idea and the few organisations with knowledge on EAP policies have failed with its implementation.
With the few organisations that have EAP enshrined in the policy guide found the counselling sessions to be very helpful. Others also emphasized that their code of conduct included punishments such as dismissal when seen drunk on the work premises during working hours as these can result in damage of properties and loss of life, with such rules these employees have no other choice than to abide by the rules. More so, HR managers mentioned that they were careful not employ applicants with alcohol use disorders.
Okay as I said earlier we have a code of conduct which is spelled out clearly and every employee of the board is aware of. If the counselling sessions fails then warning and queries proceed and sometimes even dismissal letters are issued so many employees are careful. R1.
In our institution, as human resource persons we are not allowed to recruit people who have drinking habits or uncontrollably drinking habits as all candidates we aspire to employ go through a physical examination before they are brought on board. We deal with patients not to recruit and treat people we bring on board. However if per chance an employee should exhibit such tendencies after being recruited the severity of the issue will cause the dismissal of the person.
The outcome of this study is similar to a research conducted by  who sought to examine the social representations underlying manager’s selection and hiring processes. Data from the managers using semi-structured interviews indicated that the managers were less likely to hire employees who had a history of substance use of any form presently or in the past. This implies that HR managers are reluctant in hiring employees who use substances of any form.
This paper discussed the perception and attitudes of employers towards employees with alcohol use disorder in an emerging economy. This research was conducted to provide an insight into the prevalence of alcohol use disorder (AUD) in organisations particularly healthcare institutions in Ghana. The study is relevant as AUD has an adverse effect on the productivity of employees. Although AUD in institutions account for presenteeism and absenteeism there is dearth of information in the literature. The study findings showed that a number of factors which include biological, psychological, environmental and social factors contributed to AUD. Similarly, it was observed that the perception and attitudes of employers towards employees with AUD varied across healthcare institutions. Thereby their perception and attitude about AUD had an impact on their selection and hiring processes. The study confirms that most institutions have no EAPs and those organisations with these policies have not implemented them. Which suggests that it is not all institutions that lack knowledge about EAPs but then again they are either not motivated or there are no laws which binds these organisations to do so.
5.1. Policy Recommendation
Presently, there seems to be no policy documents on EAPs, in a number of hospitals and probably worse in non-health institutions. There are some pockets of regulations in a few organisations but there is no concrete policy direction with regards to its implementation in these institutions. What can be done from policy standpoint must be a clear set of policies towards addressing AUD with EAPs. This can be realized with inputs from all stakeholders; employees, employers, government and all other relevant governing bodies. Through this they can device a roadmap of some sort for policies directed at specific needs of employees.
5.2. Research Recommendation
There is the need to expand this study to include other contexts and sectors. As this study was conducted in the Greater-Accra Region, leaving out the viewpoints respondents of 15 other regions in Ghana. Although, Accra is one of the fastest growing cities in Africa and has been described as cosmopolitan, it will be prudent for other researchers to sample participants from the other regions. Similarly, the study focused on the health sector, leaving other sectors hence the findings cannot be generalized to other context. In line with future research, the study objectives can be replicated in other sectors such as the manufacturing, agriculture, service and education to minimize common method variance (CMV).
For future studies, a quantitative study that can assess the prevalence of AUD in Ghana will be a good breaking ground. This can be achieved if a large sample size is employed. At best the use of a mixed method approach will be ideal to enhance the validity and reliability of the study outcome by triangulating the findings. Again, future researchers can use the longitudinal research design to examine the constructs over a period of time as some narratives from the HR managers presupposes that they lack touch with their employees. Thus through a longitudinal study the researchers can observe the phenomena as it unfolds. More so, other research strategies such as medical reports, supervisor reports and other employees’ observation can enrich the research findings.
The authors of this paper would like to thank all the research participants, assistant researchers and the various institutions who supported with the data collection.
EKD contributed to conceptualization, writing of the methods, supervision of data and reviewing of the work. LAA helped with conceptualization, methodology, data analysis and editing. TMA helped with reviewing, editing and supervision of the data collection. All authors reviewed the final version of the manuscript and agreed on it for publication.
Availability of Data and Materials
The data collected and analyzed during this study are not publicly available due to confidentiality and anonymity reasons. However, de-identified transcripts might be available from the corresponding author (EKD) upon reasonable request and with permission from the participating bodies.
Ethics Approval and Consent to Participate
The study procedure was approved first by the Greater Accra Regional Health Directorate ethics committee and subsequently approved by the research units of the various hospitals. Also a consent form was signed by the research participants.
This study was fully funded by the authors of this research.
AUD: Alcohol Use Disorder; C2H5OH: Ethanol; EAPs: Employee Assistance Programs; HR: Human Resource.
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