Alcohol Use and Its Relation with Demographic, Environmental, and Psychological Factors among Adolescents in Nabawan, Sabah

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J Korean Acad Fam Med. 2024;.kjfm.23.0262

Publication date (electronic) : 2024 June 7

doi : https://doi.org/10.4082/kjfm.23.0262

Selly Jaimon¹, Pravina Deligannu^,1,2,, Fredie Robinson¹

¹Department of Public Health Medicine, Faculty of Medical and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

²Department of Chemical Engineering, Faculty of Engineering Technology, Universiti Tun Hussein Onn Malaysia, Pagoh, Malaysia

^*Corresponding Author: Pravina Deligannu Tel: +60-143678506, E-mail: pravinadeligannu@ums.edu.my, pravina@uthm.edu.my

Received 2023 November 28; Revised 2024 March 9; Accepted 2024 March 16.

Abstract

INTRODUCTION

Each year, 3 million people die from alcohol-related causes worldwide, accounting for 5.3% of all fatalities. Drinking alcohol increases the likelihood of developing serious noncommunicable diseases like liver cirrhosis, cancers, cardiovascular diseases, and injuries from violence, car accidents, and collisions. These health issues include mental and behavioral disorders, including alcohol dependence [1]. Alcohol abuse, especially binge drinking and heavy episodic drinking, has negative health and social effects on the drinkers, their families, and society as a whole. Concerning Health Target 3.5 (“Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”), the Sustainable Developmental Goals place special emphasis on this target.

There has not been much research done to determine the precise scope of the issues brought on by alcohol usage in Malaysia, despite being the tenth greatest consumer of the substance worldwide. Moreover, data demonstrates that it is rising yearly [2]. Among individuals who were 13 years of age or older, the prevalence of current drinkers was 11.1%, with men drinking much more than women (15.8% versus 6.2%) [3]. Adolescence is the phase of life transitioning from childhood into adulthood where it is characterized by the age group of 10 to 19 years old. It is a critical stage of human development and is essential for laying the foundation for long-term health [4].

The highest prevalence occurs in Wilayah Persekutuan Kuala Lumpur, followed by Sarawak and Sabah. Sarawak and Sabah are Malaysian states located in East Malaysia, specifically on the island of Borneo. The population in these two states differs from the states in West Malaysia as large indigenous communities comprised most of these states [5]. In Sabah specifically, research on alcohol use among adolescents is scarce, thus preventing an accurate picture of the magnitude of alcohol use, related associated factors, and its related harm.

Statistics show that Nabawan has the most numbers of Bumiputera (99.6%), mainly of Murut ethnicity; hence, it strengthens the justification to conduct an alcohol-related study since the findings by National Health and Morbidity Survey also show a high prevalence of alcohol use among the Bumiputera Sabah [6]. The difference in sociodemographics of Nabawan might provide different numbers and specific factors for this community, thus warranting this research to further determine its association.

According to World Health Organization (WHO), a current drinker is defined as one who has consumed more than just a few sips of an alcoholic beverage (one or more standard drinks excluding for religious purposes) in the past year preceding the survey [1]. Alcohol usage is influenced by factors such as sex, age, health, a nation’s economic prosperity, lifestyle preferences, religion, and cultural standards. Additionally, these elements affect how alcohol is consumed. Adolescence is the phase of life transitioning from childhood into adulthood, characterized by the age group of 10 to 19 years old [4]. The adolescence phase can be classified into three stages: early adolescence (approximately 10–13 years old), middle adolescence (approximately 14–17 years old), and late adolescence (approximately 18–19 years old) [7]. Along with the psychological and social changes that accompany the physical changes that herald the beginning of adolescence, these developments place this phase as a crucial stage in the development of adulthood.

Age, sex, ethnicity, and religion are demographic factors associated with alcohol use. Older age has higher rates of alcohol use as compared to younger age. Age and alcohol use have a clear and substantial relationship, and it was reported that there is a trend for increased alcohol consumption as age grows [8]. Alcohol consumption globally has been a male-dominated activity, as 54% of males and 32% of aged 15 years and older females worldwide consume alcohol [9]. Male prevalence of alcohol consumption is relatively higher (36%) as compared to females (10.8%), which is consistent with the findings of the Malaysia National Health and Morbidity Survey 2019 that showed alcohol consumption was significantly higher among current drinker males as compared to females [10]. Alcohol consumption is generally associated with backgrounds of ethnicity and culture. Individuals of a particular ethnic background are more likely to consume more alcoholic beverages as compared to another ethnic [11]. Less Muslim and Catholic adolescents than non-believers drank alcohol, and those who had never done so scored higher on religiousness than those who had [12]. Low The low prevalence of Muslim drinkers is highly associated with the strict Sharia rule that prohibits any Muslims from obtaining and using alcohol and alcohol-related products [13,14].

Environmental factors, especially family environment and peer influences, play an important role in alcohol consumption among adolescents. Elements of the family environment are included in a modified conceptual model of adaptation and coping with young adult alcohol consumption and the home environment [15]. Additionally, peer influences on adolescents’ drinking behaviors are bigger than parental influences, and it has been discovered that the size of the link between friends’ drinking behaviors and those of adolescents is greater than that of parental behaviors. When it came to taking chances and making dangerous decisions, adolescents were more prone than adults to do so when around their friends [16].

Alcohol consumption has been linked to stressful situations and experiences. The theory states that alcohol lessens fear that may be connected to tension or conflict, which encourages consumption. Heavy drinking is linked to a load of stress conflict, which encourages consumption. Heavy drinking is linked to a load of stress [17]. A stressful situation’s impact on someone is partly determined by the perception of their stressfulness [18]. Increasing severity of depressive symptoms was linked to earlier onset of alcohol consumption, more frequent alcohol consumption, and more frequent intoxication, even among students with mild or moderate symptoms [19]. Despite research suggesting that anxiety decreases as children age, certain kids may experience anxiety disorders that endure until adulthood. Finding children at risk for anxiety is crucial since these illnesses can seriously affect social and other essential areas of functioning [20]. A study found that higher levels of anxiety sensitivity were associated with more alcohol use days in the previous 6 months, and it was among youth who reported having little control over their anxiety. This result supports earlier studies that showed teenagers with high anxiety sensitivity might drink to manage their worry [21].

METHODS

3. Statistical Analysis

Simple logistic regression was used to determine the association between household income, parent’s marital status, parent’s education level, parental and peer alcohol use, ever experience of verbal and physical violence, low bonding and monitoring, respondent perceived stress, depression status, anxiety status with dependent variables of which in this study is the alcohol use status of the respondents. Factors that were found to be significantly associated with the alpha value set at 0.25 in the univariable analysis were further analyzed with multiple logistic regression. Then, significant factors were determined by multiple logistic regression. Selection of variables for the multiple logistic regression models was made by comparing both forward selection (likelihood ratio [LR]) and backward elimination (LR), and statistical significance was accepted for P-values less than 0.05.

Factors associated with alcohol use among the participants were examined using multiple logistic regression. Several variables have shown significant association with alcohol use from simple logistic regression analysis, which was demographic variables (age and sex), environment variables (parent and peer alcohol use, ever experience physical violence, low bonding, low monitoring, and ever discuss problems), and psychological factors (perceived stress, generalized anxiety, and depression). Other variables that yielded a P-value of <0.25, which is considered as statistical significance [26], were also included in the multiple logistic regression, which is parent marital status (P-value=0.196), parent education level (P-value of 0.179 and 0.140). and ever experience verbal violence (P-value=0.127) (Table 1).

Table 1.

Simple logistic regression analysis for association between demographic, environmental, and psychological factors with alcohol use among adolescents in Nabawan, Sabah

Firstly, 14 variables that were entered in the first step were age, sex, parent alcohol use, peer alcohol use, parent educational level, ever experience physical violence, low bonding, low monitoring, ever discussed serious problems, perceived stress, generalized anxiety, depression, parent marital status, and ever experience verbal violence. Using a stepwise selection method (probability stepwise entry was set at 0.05 and removal at 0.1) comparing forward selection (LR) and backward elimination (LR) for better adjustment of potential confounding factors, the selection of independent variables of the preliminary model was narrowed further. Based on the forward (LR) method, the variables that yielded significant P-values are age, peer and parental alcohol use, discussing serious problems, and monitoring by parents. From the backward (LR) method, the same significant variables were yielded, excluding low bonding and experience of verbal violence, which had a P-value of more than 0.05. Hence, the forward (LR) method variables were chosen as the best fit.

RESULTS

1. General Characteristics and Prevalence of Alcohol Use among the Participants

A total of 244 adolescents participated in this study involving 11 villages. The median age among the total study population was 18 years, and the majority (54.9%) were male. Nearly all (97.1%) of the adolescents were Bumiputera Sabah, and the most reported religion was Christianity (63.5%). Table 2 shows the general characteristics of the participants based on alcohol usage (current drinkers or not current drinkers).

Table 2.

Characteristics of the study participants according to alcohol usage

There is a total of 75 (30.7%) current drinkers, which yielded the prevalence of alcohol use as 30.7% (95% confidence interval [CI], 24.92–36.48). According to the AUDIT-10, a current drinker is described as consumption of alcoholic beverages within 12 months prior to conducting the study. Out of the 75 current drinkers, low-risk alcohol use reported was 25 (33.3%), hazardous alcohol consumption was reported to be 39 (52%), harmful alcohol use was reported to be 3 (4%), while likelihood of alcohol dependence was found in 8 (10.7%) of respondents (Table 3).

Table 3.

Prevalence of alcohol use and demographic characteristics based on the category of current drinkers among adolescents in Nabawan, Sabah (N=244)

2. Factors Associated with Alcohol Use

Demographic, environmental, and psychological factors associated with alcohol use among the participants were examined using multiple logistic regression (Table 4). The result of the multiple logistic regression found that there are significant associations between age, parent alcohol use, peer alcohol use, and parents monitoring and discussing serious problems among adolescents in Nabawan, Sabah. The analysis showed that older age (18–19 years) adolescents are at higher odds (adjusted odds ratios [aOR] of 3.93 and 5.38, respectively) of using alcohol use as compared to the younger age groups (≤17 years). Adolescents with parents who consume alcohol also are more likely to use alcohol (AOR, 4.11; 95% CI, 1.77–9.54), and the same finding was shown in adolescents who have peers who also consume alcohol (AOR, 11.57; 95% CI, 4.11–32.52). In contrast, adolescents who reported having good monitoring by parents are more likely to consume alcohol as compared to those who reported low monitoring (AOR, 2.46; 95% CI, 1.16–5.20). The same paradoxical finding was found where adolescents who ever discuss serious problems with parents are at higher odds of alcohol use (AOR, 3.86; 95% CI, 1.72–8.67) as compared to those who reported never discussing serious problems.

Table 4.

Factors associated with alcohol use among adolescents in Nabawan by multiple logistic regression

Nonetheless, based on the multiple logistic regression, there is no sufficient statistical evidence to conclude that alcohol use among adolescents in Nabawan, Sabah, is associated with other demographic factors (sex, Bumiputera Sabah, Christian religion), environment factors (household income, parent marital status, parent’s education level, bonding with parents, ever experience physical or verbal violence), and psychological factors (perceived stress, generalized anxiety, depression).

DISCUSSION

The prevalence of alcohol consumption among adolescents in our cross-sectional survey was found to be 30.7% (95% CI, 24.92–36.48). The findings of this study indicate that older adolescents, specifically those in their late teens, are more likely to consume alcohol if their parents and peers also consume alcohol. On the other hand, good parental monitoring and open communication about serious issues with parents are significant factors that are associated with alcohol use among adolescents in Nabawan, Sabah.

This study has shown that there is a relatively high prevalence (30.7%) of current drinkers among adolescents in Nabawan. In comparison with Malaysia’s National Health and Morbidity Survey of 2019, where data was obtained from respondents aged ≥13 years old using the same AUDIT questionnaire, the prevalence of current drinkers was 11.1%, where Bumiputera Sabah accounted for 21.7% of the overall current drinkers. However, there was a higher prevalence among the Sarawak Dayak adolescents than in our study, at 89% [14]. From the study’s results, we may infer that the prevalence of alcohol use in rural Sabah is higher than in the national findings. Concurrently, this study implied that the Bumiputera Sabah dan Sarawak population’s alcohol use prevalence is much higher than other ethnicities.

The population of Sabah comprises 33 indigenous groups that communicate in over 50 languages and 80 ethnic dialects [27]. The largest ethnic group in Sabah, the Kadazan-Dusun, makes up over 30% of the total population (n=698,300), is the largest ethnic group in Sabah Bumiputera, followed by Bajau (n=592,400), and Murut (n=112,900). As for the administrative districts of Nabawan, it is a district with the largest percentage of Bumiputera (99%), where the Murut ethnic group makes up the bulk of the population (89%) [6]. Our study population comprises 97% of Bumiputera Sabah, with the majority being Murut sub-ethnicity. This large percentage of Bumiputera Sabah making huge discrepancy between the proportion of participants and other ethnic groups could be the factors contributing to the high prevalence of alcohol use among this adolescent group. Alcohol consumption is frequently linked to ethnic backgrounds and cultures [11], and this is especially true of the indigenous people of East Malaysia (Sabah and Sarawak), especially during festive occasions.

In our study, age demonstrated a significant association between age and alcohol use among adolescents, where late adolescents of 18 and 19 years of age are at higher odds of consuming alcohol as compared to the early-middle age group adolescents. Previous alcohol-related studies have reported age as a significant factor [8,10,14]. As for older age adolescents, it appears that parental supervision is lessened, and growing independence and self-assurance may be contributing factors to a higher predisposition to drink alcohol [28].

This study identified parental alcohol use to be associated with alcohol use among adolescents. Similar to our findings, particularly in the 17-year-old age group, both mothers’ and fathers’ alcohol consumption are significant for the risk of adolescent alcohol consumption, with increased alcohol consumption by both mothers and fathers increasing the likelihood of adolescent alcohol use while increasing the risk of adolescent inebriation [19]. This similar finding strengthens the evidence parental alcohol use affects adolescents drinking behavior, especially in the late teenage years, and that social cognitive theory, which holds that parents are significant role models, is the most likely source for this link [29]. Another significant finding was peer alcohol use association with adolescent alcohol use in our study. Adolescents were more likely than adults to take chances and make risky judgments while they were among their peers [16]. In view of the peer group usually establishing the behavioral standards for the social environment, peer interactions can significantly impact a teen’s drinking habits. As people enter adolescence, they also begin to spend less time with their parents and more time with their friends [30].

In terms of monitoring by parents, contrastingly, good monitoring by parents was found to be significantly associated with adolescents’ alcohol use, which is similar to the finding found in the previous study [31]. Adolescents view alcohol use as a stress reliever, especially when it comes to parental behaviors. Thus, if they experience stress, they turn to alcohol usage as a coping mechanism. However, this is obviously a maladaptive method of handling stress [31]. Another interesting finding is a significant association between ever discussing serious problems with parents and adolescents’ alcohol use. How frequently a child discusses serious matters with their parents measures the closeness between the child and their parents. In this situation, parents significantly influence their children’s development of attitudes, values, and lifestyle views that can promote favorable outcomes in the cultural and academic spheres [32]. Findings of good parental monitoring and discussing serious problems with parents associated with high alcohol use in multivariable analysis could explain the causality of outcomes by whether good monitoring by parents and ever discussing serious problems with parents were due to consequences of adolescents’ alcohol use or vice versa, considering that this study applied cross-sectional study design. In other words, it could be that adolescents consumed alcohol, which resulted in parents increased (good) monitoring and increased closeness (ever discussing serious problems) by parents.

This study has some limitations. First, no causal relationship could be assessed because this was a cross-sectional study. Secondly, as this study applied guided self-administered questionnaires for data collection, it might promote recall bias. At the same time, since this study has the element of sensitivity (alcohol use among adolescents), social desirability bias might occur since the questionnaire depends on the honesty and reliability of the participants. As for the same sensitivity issue, consenting participants were concentrated on those aged 18 and 19 years. These would be the limitations encountered by our study. Another limitation of this study occurred during the sampling of respondents. During data collection, most of the time, not all adolescents in one specific house are present at home. Hence, the enumerators were only able to collect data from any adolescents present during their visit.

This present study’s findings also demonstrated that older age (late) adolescents, having parents and peers who consume alcohol, good parental monitoring, and discussing serious problems with parents are the significant factors associated with alcohol use among adolescents in Nabawan, Sabah. Conclusively, policies on alcohol-related harm reduction and prevention should be developed for adolescents, especially school-based programs, programs addressing family functioning, and parent-child communication, among others, should be further looked into. School-based prevention programs that have the best chances of being effective are those that integrate the teaching of academic material with the practice of social skills, as well as focusing interventions on multiple risk factors. Strengthening social, emotional, behavioral, cognitive, and moral abilities; raising self-efficacy; enhancing social relationships with adults, peers, and younger children; and lengthier treatments are some of the factors that boost the effectiveness of the programs [33]. Hence, a school-based policy and prevention program should adapt to these factors while being suited to local settings. Future research on the school environment, adolescents’ drinking motives, and the development of practical adolescent-friendly alcohol screening tools are recommendations for improvements. Both policy and future research should take into account the appropriateness of local population settings.

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