Factors Associated with Alcohol Consumption Among Students in High-Cost Schools in Lusaka, Zambia

Introduction

Alcohol is a depressant drug that slows down the vital functioning of the body resulting in disturbed perception.¹ In 2012, there were 3.3 million deaths out of all the global deaths attributed to drinking.² Alcohol contributes to the onset of diseases and injury-related health conditions. Alcohol marketing is associated with drunkenness and problem drinking among youths.³ This highlights the arguments for the importance of restricting alcohol marketing practices as an important policy strategy for reducing alcohol use and its dire consequences among vulnerable youths. Early initiation in alcohol use is associated with drinking problem among youths in Zambia.⁴

Factors associated with alcohol consumption among secondary school students can be narrowed down to “consumption” and “effect factors.” Consumption factors are generally socio-demographic factors such as age, residence, grade point average (GPA) and education level.⁵ Other consumption factors include attitude towards alcohol consumption, parental monitoring, parental consumption of alcohol, and amount of pocket money received by students.

The attitude of a student towards alcohol consumption relates to the stance of the individual student pertaining to alcohol consumption. Positive attitudes towards alcohol consumption refer to viewing alcohol in a favorable light, while negative attitudes towards alcohol consumption refer to viewing alcohol in an adverse, more harmful light.^1,6 Parental influence, refers to the parental monitoring and to parental alcohol consumption. Parental monitoring is defined as parental behaviors that provide the parents' with awareness of their children's lives, and that consists of the regulation of their children's activities, friends, conduct and whereabouts.⁷ Parental alcohol consumption refers to the intake of alcoholic beverages by the students' parents. Pocket money is any money given to a student in-advance for use for anything other than school fees and transportation costs.

Attitude towards alcohol consumption can be formed directly by personal experience and reinforcement, or indirectly by social learning, observation, and classical conditioning.⁸ A positive attitude towards alcohol consumption is developed directly when adolescents deem that drinking leads to positive effects, when their risk perception is lower, when they have low levels of conscientiousness, and an increased interest in risk-taking.^9,10 A positive attitude towards alcohol consumption is also developed indirectly through social learning and observing their parents drink alcohol, exposure to alcohol advertisement, having high levels of western cultural influence, associating with alcohol through peers and by being in an alcohol-permissive environment.^9,10 On the other hand, a negative attitude towards alcohol consumption is also developed directly when adolescents are involved in conventional activities such as sports and religious activities, and when they show high levels of conscientiousness as part of their personality.¹⁰ A negative attitude towards alcohol consumption can be developed indirectly via learning through association and observation when the parents of the adolescents communicate their disapproval of drinking alcohol to them, by listening to alcohol prevention messages and by having peers that display with negative attitude towards drinking alcohol.^10,11 The adolescents' attitude towards drinking alcohol, along with its evaluation, will allow the prediction of their intent to drink, as will the knowledge of the specific beliefs towards alcohol consumption that others in their surroundings may have. These factors influence the adolescents' intent to consume alcohol in relation to their motivation to please those in their environment.^9,12,13

Low levels of parental monitoring is associated with an increased likelihood of alcohol use by adolescents.^6,14 Greater parental monitoring is protective against drinking and initiation of drinking.^14,15 A significant number of studies have shown that increased parental monitoring lowers the prevalence, frequency, levels of consumption and misuse of alcohol.^6,14,16,17

Parental alcohol use is associated with greater likelihood of initiation and continued adolescent alcohol use.^15,16,18,19 The magnitude of alcohol use by adolescents is directly related to the alcohol consumption of other household members.²⁰

Despite prior studies on alcohol consumption, there is still a high prevalence of alcohol use among secondary school students in Zambia.⁴ However, to our knowledge, no study in Zambia, has assessed the attitude towards drinking among secondary school students. Therefore, the objective of the study was to determine the prevalence of drinking and the effect of attitude towards drinking among secondary school students in high-cost schools; as well as the impact of parental influence and pocket money on their alcohol intake. High-cost schools, refer to schools that are located in high-cost areas. Kabulonga and Woodlands are examples of high-cost areas of Lusaka, Zambia, with low population density and rental housing costs of US$300 or more.

Methods

A cross-sectional study was performed to assess factors associated with alcohol consumption among secondary school students.

Conceptual / Theoretical Frame Work

The Theory of Planned Behavior (TPB) states that a person's intent to carry out a certain behavior is the most important determinant of that action. When an opportune and adequate moment arises, the intent is translated into an action.^{9,12,13,23,24}

The Theory of Social Control stipulates that youths commit delinquent acts because they lack a strong affective attachment to their parents and that the strength of a relationship is the most important factor in deterring delinquent behavior. Delinquent behavior predisposes adolescents to drinking. According to the Theory of Social Control, children adhere to prosocial norms when they experience a strong bond with their parents.^17,25 This theory helps us understand the importance of parental monitoring as it is a medium of connection between parents and their children.

Bandura's Social Learning Theory states that people learn from one another, via observation, imitation and modeling. It also states that the impact of the environment on behavior is mediated through cognition.²⁶ This is an important theory in understanding that the actions of parents through consumption of alcohol has an effect on adolescents' alcohol consumption.

Adolescents' attitudes about alcohol intake are influenced by their beliefs and their positive and negative evaluation of these beliefs. This evaluation is the emotional component of attitude and is determined by the motivation and strength of the intention to use alcohol. The attitude towards alcohol consumption is influenced by subjective norms such as parental monitoring and parental alcohol consumption, as well as perceived behavioral control. Parents that closely monitor their children and do not consume alcohol, influence their children to have a negative attitude towards alcohol consumption. However, parents that consume alcohol and rarely monitor their children, influence their children to have a positive attitude towards alcohol consumption. When an individual has a negative attitude towards alcohol consumption they are less likely to have intention to consume alcohol, however, when an individual has a positive attitude towards alcohol consumption they are more likely to have intention of consuming alcohol. According to the Theory of Planned Behavior (TPB), a person's intent to carry out a certain behavior is the most important determinant of that action. Therefore, when an opportune and adequate moment arises, which may occur when an individual has a high amount of pocket money spend on items such as alcohol, the intent to consume alcohol is translated into the consumption of alcohol.^{9,12,13,23,24} This is illustrated in Figure 1.

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Figure 1.

A Conceptual Frame Work of how Attitude, Parental monitoring, Parental Alcohol Consumption, and Pocket money is Related to Alcohol Consumption of Adolescents

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Results

A total of 357 students participated in the study, of which all participants were responsive which gave a response rate of 100%. Of the 357 participant students, 202 (56.58%) were males. Females tended to be younger than males (P=0.010). Overall most participants were Grade 11 afternoon students (47.90%). The majority of the participants lived with both their parents (57.42%). There was no significant difference in the proportion of participants who consumed alcohol between males (43.1%) and females (44.5%), giving an overall alcohol consumption prevalence rate of 43.7%. These results are shown in Table 2.

Table 3 shows demographic and social factors associated with alcohol consumption. Age (P=0.001), Grade (P=0.007), Opinion on alcohol consumption (P=0.012), and Smoking (P=0.001) was significantly associated with alcohol consumption.

Table 4 shows independent factors associated with alcohol consumption. Students who had a positive opinion about alcohol consumption were 3.15 (95% C.I. [1.04, 9.56]) times more likely to consume alcohol, compared to students who had a negative opinion about alcohol consumption. Students whose parents had knowledge of their whereabouts “every time” where 31% (AOR=0.69, 95% C.I. [0.69, 0.94]) less likely to consume alcohol compared to students whose parents rarely knew the whereabouts of the students. Students whose parents consumed alcohol were 76% (AOR=I.76, 95% C.I. [1.39, 2.23]) more likely to consume alcohol as compared to those whose parents did not consume alcohol. Students who were given pocket money between US$5-100 where 52% (AOR=I.52, 95% C.I. [1.03, 2.26]) more likely to consume alcohol as compared to those that were not given any pocket money.

Discussion

This study was done among secondary school students, of which the majority of students were from 12 to 19 years of age. This age group is referred to as adolescents. The prevalence of non-consumption of alcohol was found to be 56.3%, whereas a total of 43.7% of students were found to be alcohol consumers. Students who had a negative attitude towards alcohol consumption were less likely to consume alcohol compared to students who had a positive attitude towards alcohol consumption. Students who were highly monitored by their parents were 31% less likely to drink alcohol compared to those who were not monitored. Students whose parents/guardians consume alcohol were 76% more likely to drink alcohol compared to those whose parents/guardians do not consume alcohol. Students who had pocket money between $5-$100 were 52% more likely to drink alcohol compared to those that received less pocket money.

The prevalence of alcohol consumption indicated in this study is higher than that in Ethiopia at 22.2%.²⁵ In other studies done in Taiwan and South Africa, the alcohol consumption prevalence was 19.5% and 35.5% respectively.^20,26 Compared to these findings the prevalence of alcohol consumption among adolescents in Zambia is high and needs prompt intervention.

Adolescents that have a positive attitude towards alcohol consumption, perceiving it as a desirable and pleasant behavior, are more likely to have the intention of consuming alcohol, hence are more likely to drink alcohol.^9,16,23,24 In contrast, those with a negative attitude towards alcohol consumption are less likely to have intentions of consuming, and are thus, less likely to consume alcohol when an opportunity and adequate moment arises.^11,12 This is consistent with the Theory of Planned Behavior (TPB). Using the TPB, it can be said that adolescents' intent to consume alcohol, which can be determined by their attitude, is a determinant of whether they will or will not consume alcohol when an opportunity and adequate moment arises.

In reality, it is not always as clear cut that an adolescent will either have a positive or a negative attitude towards alcohol consumption. In some cases, they may have both negative and positive attitudes towards alcohol consumption. This is because the two attitudes measure different qualities and are not merely assessing opposite ends of one spectrum.¹⁰ In these cases adolescents tend to act upon an attitude that outweighs the other.^13,27 There is a stronger correlation between positive attitude towards drinking heavily, as compared to negative attitude towards drinking.^8,28 This means that when the factors leading to both attitudes toward drinking have a similar weight, adolescents with the two conflicting attitudes are more likely to drink.

Parental monitoring is one of the ways in which children experience a strong bond with their parents. In consistency with the Theory of Social Control, this will in turn prevent them from drinking when their parents prohibit them to do so. Adolescents with low levels of monitoring are predisposed to delinquent behavior and are thus, predisposed to drinking; this is also in line with the Theory of Social Control.^17,28 Parental monitoring is also linked to a decrease in delinquency due to adolescents curtailing their behavior in response to parental actions. This is because adolescents with parents that are aware of their children's whereabouts have fewer opportunities to engage in drinking. Greater parental awareness is an indicator of high-quality parent-child relationship or high levels of positive-child interaction and involvement, which are protective against vices like drinking during adolescence.²⁸ Monitoring may also reduce the likelihood of drinking by reducing negative influence from peers by limiting contact with peers who drink alcohol. Parental monitoring is a form of asserting control by parents over outside influences such as risk peer groups who indulge in consumption of alcohol.²⁹ Laird et al.²⁸ found that parents can improve their parenting skills and monitoring, which can lead to improvements in adolescents' behavior.

The effect of parents' drinking on their children's drinking can be direct or indirect.^18,30,31 By using Bandura's Social Learning Theory it can be said that adolescents can learn how to drink directly by observing the attitude and consumption of alcohol by their parents and proceeding to imitate them. By observing their parents drink, adolescents form an idea of how they can drink, and overtime it becomes ingrained as coded information that will serve them as a guide for drinking.²⁶ This is because parents are important role models to their children. The indirect effect of parental drinking on their adolescent children can be explained by using Bandura's Social Learning Theory, which also states that the impact of the environment on behavior is mediated through cognition. Adolescents receive environmental stimuli when they see their parents drinking alcohol and internalize associated cognitions, which leads to promotion of alcohol consumption.³¹ It is important for parents to be aware of the influence their drinking behavior has on their children's drinking.

The more pocket money adolescents receive, the more likely they are to use a portion to buy alcohol.^11,32 Adolescents who receive a high amount of pocket money are also at a high risk of abusing alcohol. The strong relationship between the amount of pocket money and drinking among adolescents suggests that drinking is affected by their ability to purchase alcohol from commercial sources. Adolescents with greater access to money to spend may be able to buy alcohol more easily.³³ Adolescents who drink more often will in turn need more money to buy alcohol, and therefore, they will be more likely to ask for more pocket money.³³

Conclusion and Implications for Translation

In this study, the attitude of adolescents towards alcohol, parental monitoring, parental alcohol consumption and the amount of pocket money adolescents received were predictive of the likelihood of adolescents' drinking. Therefore, interventions to combat the high levels of alcohol consumption among adolescents should include programs to help adolescents understand the dangers of alcohol use, encourage parents to monitor their children and help adolescents learn how to use their pocket money appropriately. Factors affecting alcohol consumption among adolescents interact with each other to form a complex relationship. A holistic approach should be used to address this as these factors are interrelated.