alcohol consumption among students in vietnam - caphri · 2016-06-13 · in fact, patterns of...

Alcohol consumption

among students in

Vietnam

Pham Bich Diep

.

This research was supported by an educational development grant from

the Netherlands Organisation for International Cooperation in Higher

Education (EP-Nuffic)

Production

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English Editor: Laraine Visser-Isles (Language Bureau, Rotterdam).

© Pham Bich Diep, 2016

ISBN 978-94-6233-308-6

All rights are reserved. No part of this book may be reproduced or

transmitted in any form or by any means, without the written permission

from the author or, where appropriate, the publisher of the article.

.

Alcohol consumption among

students in Vietnam

Dissertation,

to obtain the degree of doctor at Maastricht University

on the authority of the Rector Magnificus, Prof L.L.G Soete in accordance with the decision of the Board of Deans, to be defended in public on

Monday June 13, 2016 at 10.00 hours.

by

Pham Bich Diep

.

Promoters Prof. dr. Ronald A Knibbe Prof. dr. Nanne K. de Vries Assessment Committee Prof. dr. Dike Van de Mheen (Chair) Prof. dr. Hans Bosma Prof. dr. Peter Anderson Prof. dr. Henk Garretsen (Tilburg University) Assoc Prof. dr. Luu Ngoc Hoat (Hanoi Medical University)

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1. INTRODUCTION

8

Harmful drinking of alcohol is a problem not only in developed countries, but also in

developing countries. First, this chapter describes levels of alcohol consumption in the

worldwide population, as well as among adolescents and students in general, with

special focus on students in the Southeast Asia region. Then, the rationale is presented

for our specific research among university students in Vietnam. This chapter closes

with a description of the overall aims and framework of the work presented in this

thesis.

1. 1. Alcohol consumption worldwide This section describes alcohol consumption in various regions of the world compared

with the Southeast Asia region and, more specifically, with Vietnam.

1.1.1. Trends in alcohol consumption worldwide The world’s highest alcohol consumption levels are found in the developed countries,

including western and eastern Europe. Generally speaking, high-income countries

have the highest levels of alcohol consumption. Moreover, the difference in alcohol

consumption between the developed countries and developing countries has

traditionally been very high. For example, Figure 1.1 shows the trend in alcohol use

from 1961 to 1997 in developed and developing countries.

Figure 1.1: Adult (aged 15+ years) per capita alcohol consumption by development

status of the country (WHO, 2002). Note: these data exclude information from the former Soviet Union.

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1. INTRODUCTION

9

Table 1.1 presents the five-year trends (2001-2005) in recorded per capita alcohol

consumption in the World Health Organization (WHO) regions. Alcohol use is stable

or slightly decreasing in developed countries and mostly increasing in developing

countries (WHO, 2001a). Table 1.1 also shows that alcohol consumption worldwide is

relatively stable in most countries (74.9%) but is slightly increasing in about a quarter

(23.5%) of the countries. However, in the Southeast Asia region (SEAR), as much as

68% of the countries appear to have a considerable increase in alcohol consumption.

Table 1.1. Estimates of five-year trends in recorded adult per capita alcohol consumption (%), by WHO region and the world, 2001-2005 (WHO, 2014).

WHO region Increase (%) Stable (%) Decrease (%)

AFR 25.3 70.2 4.5

AMR 5.3 94.7 0.0

EMR 5.4 81.5 13.1

EUR 12.1 87.3 0.6

SEAR 68.3 31.7 < 0.1

WPR 5.1 94.5 0.4

World 23.5 74.9 1.6 Note: AFR: African Region, AMR: Americas Region, EMR: Eastern Mediterranean Region,

EUR: European region, SEAR: Southeast Asia Region, WPR: Western Pacific Region

In 2005, worldwide consumption per capital was equal to 6.13 liters of pure alcohol

consumed per person aged 15 years and older. In 2005 recorded per capita alcohol

consumption among people aged 15 years and older in the low and lower-middle

income countries was 2.97-4.41 liters while that among upper-middle and high income

countries was 9.46-10.55 liters (WHO, 2011b).

Table 1.2 shows total alcohol per capita (APC) consumption and prevalence of heavy

episodic drinking (HED) by region in 2010. The APC and HED prevalence among the

population aged ≥ 15 years in the SEAR is the second lowest compared to the other

regions, while APC among adult drinkers aged ≥ 15 years is higher than in any other

WHO region. Although the total APC among drinkers in the SEAR ranks among the

highest, the prevalence of HED ranks average compared with the other regions. This

might suggest that the population in the Southeast Asia Region does not drink as

heavily as the population in the European and the American Regions. However, since

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1. INTRODUCTION

10

Vietnam belongs to the Western Pacific Region and now also belongs to the group of

lower-middle income countries, the APC of Vietnam (see section 3.3 below) has also

increased and is similar to that in the Southeast Asia Region.

Table 1.2: Total alcohol per capita consumption (in liters of pure alcohol) and

prevalence of heavy episodic drinking (HED) in the total population aged 15 years

and older (15+ years) and among drinkers (15+ years) by WHO region and the

world, 2010 (WHO, 2014)

WHO region Total population

(aged 15+ years)

Among drinkers only

(aged 15+ years)

Total APC HED

prevalence

(%)

Total APC HED

prevalence

(%)

AFR 6.0 5.7 19.5 16.4

AMR 8.4 13.7 13.6 22.0

EMR 0.7 0.1 11.3 1.6

EUR 10.9 16.5 16.8 22.9

SEAR 3.4 1.6 23.1 12.4

WPR 6.8 7.7 15.0 16.4

World 6.2 7.5 17.2 16.0 Note: APC: alcohol per capita, HED: heavy episodic drinking; AFR: African Region,

AMR: Americas Region, EMR: Eastern Mediterranean Region, EUR: European region,

SEAR: Southeast Asia Region, WPR: Western Pacific Region

Worldwide, alcohol consumption is generally more popular among men than women

(WHO, 2011b). Table 1.3 shows gender differences in drinking throughout the world;

it can be seen that gender differences are highest in the lower middle-income

countries, a group that includes Vietnam.

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1. INTRODUCTION

11

Table 1.3. Gender difference in drinking behavior by income group (WHO, 2014).

Income group Proportion of current drinkers among all adults

(15+ years) (%)

Prevalence of HED among

drinkers (15+ years)

(%)

Males

(%)

Females

(%)

Males/

Females

Males

(%)

Females

(%)

Males/

Females

Low income 24.9 11.9 2.1 14.5 5.4 2.7

Lower-middle income 28.0 11.0 2.5 15.8 2.6 6.2

Upper-middle income 57.3 32.5 1.8 24.0 4.9 4.9

High income 75.6 63.6 1.2 30.2 13.4 2.3

World 47.7 28.9 1.6 21.5 5.7 3.8

1.1.2. Consequences of alcohol consumption worldwide Although alcohol consumption and related problems vary across countries, the burden

of disease and death is considerable in most countries. The harmful use of alcohol

ranks among the top five risk factors for disease, disability and death throughout the

world. For example, in 2012, alcohol consumption and related problems were

attributed to about 3.3 million deaths, or 5.9% of all global deaths, or 139 million

DALYs (disability-adjusted life years), or 5.1% of the global burden of disease or

injury (WHO, 2014). Figure 1.2 presents the global distribution of death due to

alcohol by various diseases and injury in 2004 (WHO, 2011b).

Figure 1.2: Global distribution of all alcohol-attributable deaths by disease or injury

in 2004 (WHO, 2011b).

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1. INTRODUCTION

12

1.2. Alcohol consumption among adolescents and students This section describes alcohol consumption among adolescents throughout the world,

as well as in Southeast Asian countries and, more specifically, in Vietnam.

1.2.1. Trend of alcohol consumption among adolescents, students and

adults There is a strong significant correlation between high alcohol per capita consumption

among adults and alcohol consumption among adolescents in 68 countries (Fuhr &

Gmel, 2011). Of the 82 responding countries in the WHO Global Survey on Alcohol

and Health (2008) concerning the five-year trend of drinking among 18-25 year olds,

80% of the countries reported an increase, 11% a decrease, 6% were stable and 12%

showed inconclusive trends (WHO, 2011b). Figure 1.3 shows the prevalence of heavy

episodic drinking among adolescents aged 15-19 years compared with adults, by

WHO region.

Figure 1.3: Prevalence (%) of heavy episodic drinking (HED) among the total population

aged 15 years and older and adolescents (15-19 years) and the corresponding adolescents-

to-all ratios of HED prevalence, by WHO region and the world, 2010 (WHO, 2014). AFR: African Region, AMR: Americas Region, EMR: Eastern Mediterranean Region, EUR:

European region, SEAR: Southeast Asia Region, WPR: Western Pacific Region

In the Southeast Asia region, there is smaller difference in heavy episodic drinking

(HED, defined as 60 or more grams of pure alcohol on at least one single occasion at

least monthly) than in any other region. Notably, HED prevalence among adolescents

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1. INTRODUCTION

13

is lower than that among adults, but this was observed only in the Southeast Asia

region.

1.2.2. Alcohol consumption among students and adolescents Prevalence of alcohol use is high among students, especially European students. A

study conducted in 36 European countries in 2011 shows that at least 70% of the

students aged 16 years have drunk alcohol at least once during their lifetime, with an

average of 87% (Hibell et al., 2012); these percentages range from 88.5-91.9% among

Brazilian students (Karam, Kypri, & Salamoun, 2007) and 14.4% in Egyptian

students, that have ever tried alcohol (Karam et al., 2007). Compared to developed

countries, alcohol consumption among young people in Vietnam is lower (see Section

3 below).

Heavy drinking

As described above, among both adults and adolescents, the prevalence of heavy

episodic drinking is highest in Europe followed by the Americas. Similarly, binge

drinking is popular among students, especially in Australia, New Zealand and Europe.

For example, among 36 European countries, on average 39% of the students (aged 16

years) have had five drinks or more on one occasion during the past 30 days: the

highest proportions are found in Denmark and Malta (56%) and the lowest in Iceland

(13%) (Hibell et al., 2012). Among 81% New Zealand university student drinkers,

37% reported one or more binge episodes in the last week, 14% of women and 15% of

men reported 2+ binge episodes in the last week, 68% scored in the hazardous range

(4+) on the AUDIT consumption subscale (K. Kypri et al., 2009), and 63% reported to

drink in the hazardous/harmful range (score ≥8 on the AUDIT) (Kypri & Stephenson,

2005).

In fact, patterns of drinking vary across countries (Hibell et al., 2012). A cross-country

study among students showed that hazardous drinking is lower in Asia and Africa but

higher in Australia, Europe, and North and South America (Karam et al., 2007). The

prevalence of binge drinking in the past 30 day was 23.5% among students in China

(Ji, Hu, & Song, 2012); among male and female students in Thailand, binge drinking

rates are 15.7% and 6.3%, respectively (Chaveepojnkamjorn, 2012), while 0.8% of

students in Hong Kong reported alcohol-related problems (Griffiths et al., 2006).

High volumes of alcohol consumption and risky single-occasion drinking among

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1. INTRODUCTION

14

university students have been associated with considerable harm, both to those who

consume alcohol and to others. There are reports that over 25% of young male

mortality and approximately 10% of young female mortality are related to alcohol

(Moreira, Smith, & Foxcroft, 2009). Also, in Europe, more than 1 in 4 deaths among

men (aged 15-29 years) and 1 in every 10 deaths among young women are alcohol

related (Jurgen Rehm & Monteiro, 2005). Globally, the proportion of alcohol

attributable male deaths was highest among the age group 15-29 years (WHO, 2011b).

However, the difference between 15-29 year olds and 30-59 year olds in the Southeast

Asia region is weaker than that in the Americas and in Europe (Figure 1.4).

Figure 1.4: Proportion of alcohol-attributable male deaths (%) of all male deaths by

age group and WHO region, 2004. AFR: African Region, AMR: Americas Region, EMR: Eastern Mediterranean Region, EUR:

European region, SEAR: Southeast Asia Region, WPR: Western Pacific Region

1.2.3. Alcohol consequences Young people are more likely than adults to report alcohol-related problems. The most

frequently reported drinking problems of young people range from normal negative

consequence to very seriously ones. The problems can be related to school (e.g.

academic impairment or higher levels of absence), or might include short and long-

term physical problems like hangovers, vomiting, blackouts, physical illnesses, and

violence (Best, Manning, Gossop, Gross, & Strang, 2006; Bullock, 2004; C. J. Cronin,

1991; Crystal L. Park & Grant, 2005; Perkins, 2002). Furthermore, they can cause

legal problems such as being arrested whilst driving, physically hurting someone,

fighting (College aim: Alcohol Intervention Matrix; D.S. Anderson & A. Gadaleto,

2001; Hibell et al., 2012; Moreira et al., 2009), unwanted, unplanned and unprotected

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1. INTRODUCTION

15

sexual activity, sexual harassing someone (Hallett et al., 2012; Hingson, Zha, &

Weitzman, 2009; Langley, Kypri, & Stephenson, 2003; Mohler-Kuo, Dowdall, Koss,

& Wechsler, 2004), serious problems with friends/parents (Hibell et al., 2012),

alcohol-related car crashes and other unintentional injuries (Adlaf, Demers, &

Gliksman, 2005; Hibell et al., 2012), and getting into trouble with the police (Hibell et

al., 2012; National institute on alcohol abuse and alcoholism, 2015). Alcohol use can

also lead to abuse of other drugs (Best et al., 2006). Finally, heavy drinking in young

persons may increase the risk for future alcohol dependence and alcohol-related injury

(WHO, 2001a).

1.3. Need for alcohol research among students in Vietnam 1.3.1. Students in a period of transition and vulnerability University students (mostly aged 18-25 years) on the verge of adulthood, are likely to

undergo significant changes in social status, roles, responsibilities, and institutional

context (Arnett, 2000). Emerging adulthood (often described as age 18-25 years) is

often seen as a combination of late adolescence and stages of early adulthood. For

example, Arnett’s theory of emerging adulthood describes late adolescence as a period

involving many prospects related to romance, work, and worldwide views (Arnett,

2000). In Vietnam, most students enter a university that is not located in or (often) not

even near their home town, i.e. they generally have to leave home to enter college.

This means that they have to separate from their family, friends and familiar settings.

They also have to adjust to an environment that presents new academic and social

demands, which might be a source of substantial risk and/or vulnerability. This

exposure of students to a new setting can yield new friends and a new lifestyle, but

can also increase the chance of new risky behavior. This transitional period is often

associated with risky hazardous, such as excessive alcohol consumption. Moreover,

university students generally tend to drink both more, and heavier, than their non-

university peers (General Statistics Office, 2014; Karam et al., 2007; Kypri, Langley,

& Stephenson, 2005).

1.3.2. Vietnam: changing society and economy Vietnam is a nation with a population of nearly 91 million (in 2014) (General

Statistics Office, 2014), 80% of whom live in rural areas. Since the ‘Doi Moi’ policy

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1. INTRODUCTION

16

was introduced in Vietnam in 1986, the Vietnamese government has reformed the

economy, moving from a centrally planned to a market-oriented economic system; this

has had a significant impact on economic development in Vietnam. Between 1990 and

2010, Vietnam’s economy has grown at an annual average rate of 7.3% and the per

capita income has almost quintupled. This rapid economic growth enabled Vietnam to

develop from an extremely poor country to a lower-middle income country by 2010

(Vietnam development report 2012). In 1990 the gross domestic product per capita in

Vietnam was 98 US$ per year and this had risen to 1333 US$ in 2010, i.e. 13.6 times

higher than in 1990 (The World Bank, 2015). The rapid expansion of the economy

was accompanied by a high level of growth of international trade, large-scale inflow

of foreign direct investment, a dramatic reduction in poverty, and almost universal

access to primary education, healthcare, and life-sustaining infrastructure and housing.

On the other hand it is also reported that, since the impressive economic development,

there has also been a considerable increase in alcohol consumption (WHO, 2001b).

Firstly, since the open door policy, Vietnam has allowed joint business ventures,

including companies/factories producing beer and other alcoholic beverages, which

has led to the increasing availability and visibility of both national and imported

brands. Secondly, alongside the economic development, the infrastructure was also

developed, leading to the introduction of foreign media, internet access, and a rapid

increase in tourism. Therefore, the Western lifestyle has slowly been introduced.

Many more Vietnamese can now afford to socialize with friends and engage in

business ‘over drinks’. Together with global integration, the lifestyle of Vietnamese

consumers has evolved and Vietnam’s culture has become increasingly more

Westernized, especially among the younger population. A growing number of young

consumers see this as part of a highly desirable social life, with the consumption of

alcoholic drinks at a bar or restaurant becoming increasingly popular.

Despite the economic development and changes in lifestyle with significant influences

from outside the country leading to a substantial increase in alcohol consumption,

Vietnam has no written national policy/national action plan related to alcohol (WHO,

2014). The existing policy measures related to alcohol include: excise tax on

beer/wine/spirits, 18 years as a minimum age for on- and off-premises sale of

alcoholic beverages, restriction on places for on- and off-premises sales of alcoholic

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1. INTRODUCTION

17

beverages, legal regulations related to alcohol advertising/product placement, and a

drunk driving law, i.e. a blood alcohol concentration (BAC) level at which driving is

illegal (BAC=0 to 0.05 g/dld for two-wheelers and cars). However, enforcement of the

drunk driving law is currently very low, with an estimated score of 3 out of 10 (where

0=not effective and 10=highly effective) (WHO, 2013; World Health Organization,

2009). Additionally, well-informed educational efforts in Vietnam with regard to

alcohol consumption are very limited (L. M. Kaljee et al., 2005). Although advertising

of spirits is banned on national television and radio, there are little or no restrictions on

the advertising of beer and wine on television and radio, or on printed media and

billboards. Moreover, the advertising and promotion restrictions are also only partially

or weakly enforced (WHO, 2004b).

1.3.3. Alcohol consumption in Vietnam Alcohol consumption of persons aged 15 years and older in Vietnam (both recorded

and unrecorded) increased dramatically from about 1.6 liters in 1990 to 6.6 liters in

2010 (a remarkable increase of 412%) (WHO, 2004a, 2014). However, only limited

data are available to describe the drinking patterns in Vietnam (Table 1.4).

Table 1.4: Alcohol consumption in Vietnam in 2003 (WHO, 2011b) and in 2010

(WHO, 2014).

Indicator 2003 2010 Male

(%) Female

(%) Total (%)

Male (%)

Female (%)

Total (%)

Lifetime abstainer (15+ years) 38.5 95.2 67.1 34.9 62.9 49.3 Former drinkers (15+ years) 14.1 3.5 8.8 16.6 8.4 12.4 Abstainers (15+ years), past 12 month

52.6 98.7 75.9 51.5 71.4 61.7

Heavy episodic drinking (15-85 years)1

22.1 22.7

Heavy episodic drinking2 2.6 0.2 1.4 Pattern of drinking score (1= least risky to 5=risky)

3 3

Alcohol use disorders 4.1 0.14 8.7 0.9 4.7 Alcohol dependence 5.9 0.1 2.9 Type of beverage: beer 97 97 Years of life lost score in 2012 5 (from score 1=least to 5=most)

Note: 1Had at least 60 g or more of pure alcohol on at least one occasion weekly 2 Had at least 60 g or more of pure alcohol on at least one occasion in the past 30 days

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1. INTRODUCTION

18

Table 1.4 shows that between 2003-2010 there were no major changes in abstention

levels and former drinkers, but a relatively strong increase in alcohol use disorders

among men (4.1-8.7%) and women (0.14%-0.9%).

However, the estimation of heavy drinking at the national level seems to be lower than

that estimated for the rural areas. A survey of 3,424 people in rural areas of Vietnam

indicated that among men and women, the prevalence of alcohol-related problems was

25.5% and 0.7%, respectively; weekly and daily binge drinking were 5.7% and 3.6%

among men, whereas binge drinking among women was virtually nonexistent (K.B.

Giang, Allebeck, Spak, Van Minh, & Dzung, 2008). A comparison survey among nine

rural areas in four Asian countries (Bangladesh, Indonesia, Thailand and Vietnam)

reported that the prevalence of at-risk drinkers ( ≥4 standard drinks per day among

women and ≥5 standard drinks per day among men) was highest among adults in two

rural areas in Vietnam (ranging from 8.4-15.3%), respectively (Huu Bich et al., 2009).

Notably, men were from 90 (95% CI: 26.9-298.5) to 100 times (95% CI: 39.9-313.5)

more likely to be at-risk drinkers than women in two rural areas in Vietnam.

Therefore, it can be concluded that in the rural areas in Vietnam, the gender

differences in drinking are larger than in the other countries included in that study

(Huu Bich et al., 2009). Compared to the older population, the prevalence of alcohol

consumption among Vietnamese youth was higher. A survey and assessment of

Vietnamese youth (SAVY) in 2004 showed that the highest proportion of drinkers is

found among the 22-25 year olds (62.2% compared to 57.9% among those aged 18-21

years) (SAVY, 2005). Among the 480 surveyed youth (Vietnamese youth aged 15-20

years), 29.2% had consumed alcohol of which 17.6% reported intoxication in the past

6 months. While young men were significantly more likely to drink than young

women (p

1. INTRODUCTION

19

1.4. Aims of this thesis The main aims of the work in this thesis are to examine:

• the drinking patterns of students and the consequences of alcohol use among

students (Chapters 2, 3, 4, 5 and 6)

• the direct and indirect effects of alcohol expectancies through drinking motives

on alcohol outcomes (Chapter 5)

• the explanatory value of drinking context and individual characteristics for

alcohol consumption (Chapter 6).

1.5. Framework of the thesis The consumption of alcohol not only depends on personal choices and factors, but is

also strongly influenced by the environment. Data from studies on university samples

consistently indicate that alcohol is consumed for various purposes, for different

psychological effects, and in different contexts (Baer, 2002). Since alcohol

consumption has been explained by both individual and environmental variables, the

model used in this thesis is derived from the modified Predisposing, Reinforcing and

Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model;

this is a population-based epidemiologic planning framework that is also ecological in

its perspective. The model directs planners to determine health problem characteristics

in various population groups. This model has also been used as the basis for health

promotion planning in hundreds of programs.

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1. INTRODUCTION

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main aims of this study as described above:

Part 1 describes the prevalence and drinking patterns of alcohol consumption and

alcohol-related problems among students and the harms that students experience from

the drinking of others (Chapters 2, 3,4, 5 and 6).

Part 2 explores the indirect and direct effects of alcohol expectancies through

drinking motives on alcohol outcomes (Chapter 5).

Part 3 examines the contribution of drinking context and individual characteristics to

the explained variance of alcohol consumption (Chapter 6).

All five studies are based on cross-sectional data: details on the design of each paper

are given in Chapters 2 to 6.

1.6.1. Part 1: Drinking pattern The PRECEDE model is used to help understand the determinants of drinking

behavior among students in Vietnam. In other words, the drinking pattern helps to

identify which behavior(s) need specific focus for prevention purposes; in addition,

the drinking patterns also offer some explanations, because evidence-based prevention

focuses on the determinants of these behaviors. Harmful use of alcohol is defined as

drinking that causes physical, psychological and social harm to the drinker himself or

herself. However, in the case of alcohol (and more general substance use) it is also

necessary to include the harm that an individual’s consumption may cause other

persons, other than the drinker. When we first started the work presented in this thesis,

there was a serious lack of information related to drinking patterns among students in

Vietnam. The information provided by the WHO reports for various regions

(including Vietnam), generally only give some idea about the level of alcohol

consumption in a country. Therefore, additional survey data are needed to be able to

describe in more detail how much student’s drink, how often they drink, and where

they drink, etc. In the context of this thesis, we focus on the frequency of drinking, the

quantity of drinking, and the context of alcohol consumption. In addition, besides

examining gender differences, we examine differences in age groups, and the place of

habitation with regard to drinking patterns, as this is useful when aiming to identify

risk groups for certain behaviors.

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1. INTRODUCTION

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1.6.2. Part 2: Individual factors related to drinking Individual characteristics (including gender, age and cognitive factors) are also

associated with alcohol consumption. Many studies have shown that gender and age

are associated with alcohol consumption and alcohol-related problems (S.

Assanangkornchai, A. Mukthong, & T. Intanont, 2009; Pham B Diep, Alan R Clough,

Hien V Nguyen, Giang B Kim, & Petra G Buettner, 2010; Pham Bich Diep, Knibbe,

Giang, & Vries, 2013; Harrell & Karim, 2008; Jamison & Myers, 2008; Kim et al.,

2009; Emmanuel Kuntsche, Gmel, Wicki, Rehm, & Grichting, 2006; Kypri, Paschall,

Langley, Baxterd, & Bourdeau, 2010; Vantamay, 2009; YEH, 2006). Among

cognitive factors, alcohol expectancies and drinking motives are often described as

two equivalent determinants of alcohol use and problematic drinking among young

people (Baer, 2002). This thesis selected these two individual factors since they have a

strong theoretical context indicating that they are (potentially) very relevant

determinants (Bot, Engels, & Knibbe, 2005; M Lynne Cooper, Kuntsche, Levitt,

Barber, & Wolf, 2015; M Lynne Cooper, Marcia, B, & Michael, 1992; M. L. Cooper,

Frone, Russell, & Mudar, 1995; Cox & Klinger, 1988, 1990; Goldsmith, Tran, Smith,

& Howe, 2009; Kuntsche et al., 2014; Kuntsche, Knibbe, Engels, & Gmel, 2007; E.

Kuntsche, Knibbe, Gmel, & Engels, 2005; Nemeth et al., 2011) and because these

factors are supposed to be more easily accessible for prevention efforts (Cox &

Klinger, 1988) and can be changed through intervention.

Alcohol expectancies are the beliefs of an individual about the effect of alcohol if

he/she consumes alcohol. The principles of the theory are derived from the Social

Learning perspective (Bandura, 1971), that learning established through research on

observable behavior with constructs based on cognitive processes that are, themselves,

not directly observable. Therefore, although an individual may never drink alcohol,

he/she still has the expectation of drinking through the social learning perspective

(Jones, Corbin, & Fromme, 2001). Alcohol expectancies are associated differentially

with both frequency and quantity of drinking. In contrast to alcohol expectancies,

drinking motives are assumed to be the individuals' decisions to drink in order to

achieve certain valued outcomes (M. Lynne Cooper, 1994). Therefore, motives can

only be assessed among individuals who actually consume alcohol. Drinking motives

represent a subjectively derived decisional framework for alcohol use that is based on

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1. INTRODUCTION

23

personal experience, situation and expectancies. Motives are assumed to be the most

proximal predictors of alcohol use, the gateway through which more distal influences,

such as expectancies, are mediated (M. Lynne Cooper, 1994; Cox & Klinger, 1988;

Kuntsche et al., 2007). There is increasing evidence to support the hypothesis that

drinking motives mediate the link between alcohol expectancies and different alcohol-

related outcomes (M. L. Cooper et al., 1995; C. Cronin, 1997; Kuntsche et al., 2007;

Kuntsche, Wiers, Janssen, & Gmel, 2010; Read, Wood, Kahler, Maddock, & Palfai,

2003). Until recently, all evidence was drawn from Western industrialized countries,

including Australia, Hungary, Switzerland and the USA (Catanzaro & Laurent, 2004;

Greenfield, Harford, & Tam, 2009; Hasking, Lyvers, & Carlopio, 2011; Kuntsche et

al., 2007; Tyne, Zamboanga, Ham, Olthuis, & Pole, 2012; Urban, Kokonyei, &

Demetrovics, 2008).

From the intervention point of view, the factors that are most proximate to drinking

are particularly important. The study in Chapter 5 aimed to further elucidate the most

proximal factors of drinking among Vietnamese students.

1.6.3. Part 3: Contribution of contextual factors and motives to the

explanation of alcohol consumption It is recognized that alcohol use is determined not only by individual factors but also

by contextual factors. Many studies have indicated that drinking patterns of students

vary with drinking environment and individual characteristics (Alia & Dwyer, 2010;

Borsari & Carey, 2001; J. D. Clapp et al., 2003; J. D. Clapp, Shillington, & Segars,

2000; J. Clapp, Reed, Holmes, Lange, & Voas, 2006; J. Clapp & Shillington, 2001;

Demers et al., 2002; Harford, Wechsler, & Seibring, 2002; Knibbe, Oostveen, & van

de Goor, 1991; Kypros Kypri, Mallie J. Paschall, John D. Langley, et al., 2010; Kypri,

Paschall, Maclennan, & Langleyb, 2007). However, very few studies have examined

how large a part of drinking is explained by contextual versus individual factors. To

increase our understanding and to enable to prioritize the mix of specific interventions

needed for prevention, the study in Chapter 6 uses a multilevel analysis to explore the

extent to which individual variables and drinking context variables contribute to

alcohol consumption per occasion. Individual factors, especially the more cognitive

variables, mostly indicate interventions aimed to influence the ‘demand side’, i.e. the

individual’s motives to drink. Contextual factors mostly indicate the ‘supply side’ or

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1. INTRODUCTION

24

(contextually determined) opportunities to drink. The type of intervention suitable to

influence the demand side or supply side differ substantially and, therefore, more

insight is needed to establish how important individual versus contextual factors are

for the level of alcohol consumption. This will help to establish which mix of

interventions will be most appropriate and, hopefully, most successful.

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2. ALCOHOL CONSUMPTION AND ALCOHOL-‐RELATED PROBLEMS AMONG VIETNAMESE MEDICAL STUDENTS

26

Abstract Introduction and Aims. This study examined prevalence and predictors of alcohol

consumption and alcohol problems in a sample of medical students in Vietnam.

Design and Methods. A cross-sectional survey using a multi-stage cluster sampling

approach was conducted in 2007 in two universities in Vietnam. The students (n =

619, 100% response rate) completed questionnaires based on the Alcohol Use

Disorder Identification Test. A score of ≥8 defined presence of alcohol problems. Data

analyses adjusted for the cluster sampling approach.

Results. Overall 65.5% of students had drunk alcohol during the previous year while

alcohol problems were detected in 12.5%. Male students, students who reported that

their family members drank and students who reported that their flat mates were

drinking were more likely to be current drinkers. Male students were 14.3 times more

likely to have an Alcohol Use Disorder Identification Test score of ≥8 compared with

female students (P = 0.005). Discussion and Conclusions. Intervention programs

focusing on male students and their social environment are warranted. As Vietnamese

society rapidly modernises prevention programs for female students may also be

needed.

Key words: medical student, alcohol consumption, alcohol-related problem, Vietnam,

sex difference.

.

2. ALCOHOL CONSUMPTION AND ALCOHOL-‐RELATED PROBLEMS AMONG VIETNAMESE

MEDICAL STUDENTS

27

2.1. Introduction Most societies look to medical students as their future health care professionals.

Physicians’ health habits can affect their patient counseling practices (Frank, 2004)

and the vast majority of medical students (94%) feel that it is a medical doctor’s

responsibility to intervene with alcohol problems in their patients (Cape, Hannah, &

Sellman, 2006). Heavy drinking in young people leads to future alcohol dependence and alcohol

related injury (WHO, 2001a). Medical students are young people in whom alcohol has

been shown to be associated with violence (Bonomo, Coffey, & Wolfe, 2001) and

adverse impacts on academic achievement (Jennison, 2004). Alcohol consumption

among medical students is known to have increased since 1990 (Boland et al., 2006;

Newbury_Birch, Walshaw, & Kamali, 2001). Studies in the UK, Norway, and

Germany indicate that drinking to cope with tension (Kjobli et al., 2004; Tyssen,

Vaglum, AAsland, Gronvold, & Ekeberg, 1998), students’ living situation, frequency

of drunkenness and number of drinks consumed (Keller, Maddock, Laforge, Velice, &

Basler, 2007) are associated with alcohol problems while missing lectures and fighting

are associated with alcohol consumption (Newbury-Brich, White, & Kamali, 2000).

Between 28% and 53% of medical students drink over recommended safe limits

(Granville-Chapman, Yu, & White, 2001; Newbury-Brich et al., 2000; Pickard, Bates,

Dorian, Greig, & Saint, 2000) and between 14% and 19% drink at hazardous levels

(Kjobli et al., 2004; Tyssen et al., 1998). The number drinking over safe limits and

drinking at hazardous levels (≥5 drinks per occasion) increases from junior to senior

medical students and into the first year of their medical careers (Akvardar, Demiral,

GulErgor, & Ergor, 2004; Newbury_Birch et al., 2001). In Turkey, the proportion at

risk of alcohol abuse among junior medical students (8.5%) is nearly twice that of

senior ones (4.8%) (Akvardar et al., 2004).

A recent survey and assessment of Vietnamese youth (SAVY) in 2004 showed that the

highest drinking rate occurs among 22-25 year olds (62.2%), followed by 18-21 year

olds (57.9%) (United Nations, 2004). However, no investigations of the prevalence of

alcohol use, alcohol problems and associated factors among medical students have

been published. Investigating factors associated with alcohol problems in medical

students is important for planning intervention programs to better educate future

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28

doctors. This manuscript describes results of a preliminary investigation into the

drinking habits of Vietnamese medical students.

2.2 Methods 2.2.1. Setting The study was conducted at Hanoi Medical University (HMU), the oldest and most

influential medical school in Vietnam. Thai Nguyen Medical School (TNMS), by

contrast, is a young organization providing health care professional training for the

Northern Mountain region. Thai Nguyen Province is much less developed than the

Hanoi region.

2.2.2.Sampling A multi-stage sampling strategy was used with the University being the first stratum

and year levels (second, third and fifth) the second. Sample size was calculated to

detect a level of 10% of the study population having alcohol problems, with an

absolute precision of +/- 5% and 95% confidence. Accordingly, sample sizes for each

year level were 139, making a total minimum sample size of 417. The initial sample

size was increased subsequently by 5% for losses, 20% to control for confounding and

20% for the design effect, making a total targeted sample size of 605. Two classes of

each year level in each university were randomly selected. All students in the selected

classes were invited to participate in the research and all (100%) accepted, making a

final sample size of 619.

2.2.3. Questionnaire A self-administered, anonymous questionnaire was developed and pre-tested with

HMU medical students and revised before it was used. Questions included social and

demographic factors, the Vietnamese version of the Alcohol Use Disorder

Identification Test (AUDIT) and alcohol consumption in the previous month. The

AUDIT consists of ten questions with a total possible score of 40. Questions 1 to 8 can

be scored from 0 to 4 and questions 9 and 10 can be scored 0, 2 or 4. Although other

instruments including CAGE and Michigan Alcoholism Screening Test (MAST) are

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MEDICAL STUDENTS

29

used to screen alcohol problems at the primary level, AUDIT has been shown to

provide more accurate results (Gache et al., 2005). Additionally, AUDIT is

recommended by the World Health Organization (WHO) for screening alcohol

problems at the primary level with a cut off point of 8 (Babor, Higgins-Biddle,

Saunders, & G.Monteiro, 2001). This cut off point can identify alcohol problems in

Vietnamese people using the Vietnamese AUDIT version (Kim Bao Giang, Fredik

Spak, Truong Viet Dzung, & Peter Allebeck, 2005).

Questions about volume of beer and wine consumed last month using a beverage-

specific, quantity-frequency method were also asked. Although this method cannot

describe overall frequency of drinking, it is an effective method to assess the volume

of alcohol consumed and drinking patterns (Gmel, Graham, Kuendig, & Kuntshe,

2006).

2.2.4. Exposure measures • Standard drink (SD) = 1 can beer (330 ml at 5%) = 1 glass wine (140 ml at

12%) = 1 shot spirit (40 ml at 40%) = 12.6 grams of pure alcohol. Pictures

describing common beverages in Vietnam with their ethanol levels and

corresponding units for SD was enclosed in the questionnaire to help

students to estimate their alcohol intake by SD.

• Abstainers: students who reported never drinking in their life,

• Ex-drinkers: students who had not consumed alcohol in the previous 12

months.

• Drinkers: students who reported drinking alcohol at least once during the

previous 12 months.

• Alcohol problems: drinkers having an AUDIT score of ≥8.

2.2.5. Ethics This study was approved by the Research Scientific Department at HMU and the

Human Research Ethics Committee of James Cook University. All participants gave

their written consent.

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30

2.2.6. Data analysis Numerical data were described using median values and inter-quartile ranges (IQR).

All analyses were adjusted for the cluster sampling approach. Logistic regressions

compared drinkers (n= 400) with the combined group of abstainers and ex-drinkers.

Results were presented as odds ratios (OR) with 95%-confidence intervals (95%-CI).

Similarly, students with alcohol problems (AUDIT score ≥8) were compared with

those with an AUDIT score of


MEDICAL STUDENTS

31

likely to report drinking than younger students (less than 22 years old) (OR=1.9; 95%-

CI= [1.2, 3.2]). Students with fathers who were high school educated, were less likely

to drink alcohol than those whose fathers had post high school education (OR= 0.74,

95%-CI= [0.60, 0.90]). Students whose family members never drank were less likely

to be alcohol users than those with family members who drank at least once a month

(OR= 0.13, 95%-CI= [0.02, 0.93]). Alcohol users, compared with non-users, were

more likely to have flat mates who were drinkers (OR=4.9; 95%-CI= [2.3, 10.4]) and

to be smokers (OR=22.4; 95%-CI= [1.8, 278.3]) (Table 2.1).

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32

Table 2.1. Social and demographic characteristics of 400 medical students who consumed alcohol during the previous year compared with 92 who reported never

drinking alcohol and 119 who reported not drinking in the previous year. The medical students were surveyed in two universities in Vietnam.

Abstainers N = 92

Ex-drinkers N = 119

Drinkers N = 400

OR*

95%-CI**

p-value

Gender Female† 81 85 149 1 Male 11 34 251 6.2 3.1, 12.6 p = 0.001 Age group =22 years 31 60 239 1.9 1.2, 3.2 p = 0.019 Ethnicity Kinh† 79 96 328 1 Other 8 19 52 1.0 0.45, 1.3 p = 0.935 Major GP† 79 105 367 1 Traditional MD 13 13 33 0.64 0.25, 1.6 p = 0.267 Living (home area) City or town† 57 67 223 1 Lowland 21 34 100 1.0 0.64, 1.6 p = 0.954 Mountain 11 16 65 1.3 0.66, 2.7 p = 0.342 Other 2 1 12 2.2 0.39, 12.7 p = 0.291 Other studies No† 76 87 326 1 Yes 14 30 72 0.82 0.33, 2.0 p = 0.590 Part-time job No† 76 105 347 1 Yes 14 12 50 1.0 0.51, 2.0 p = 0.991 Father’s education ≤ Primary education 3 3 20 1.6 0.59, 4.5 p = 0.271 Secondary education 23 26 101 1.0 0.57, 1.8 p = 0.981 High school 25 51 115 0.74 0.60, 0.90 p = 0.012 Post high school† 41 39 164 1 Mother’s education ≤ Primary education 6 11 34 0.97 0.40, 2.3 p = 0.926 Secondary education 31 24 97 0.85 0.53, 1.4 p = 0.428 High school 22 42 117 0.88 0.57, 1.4 p = 0.499 Post high school† 33 40 151 1 Family members drink Never 10 1 3 0.13 0.02, 0.93 p = 0.044 < once a month 16 35 74 0.67 0.43, 1.0 p = 0.065 ≥ once a month† 66 82 322 1 Live with family No† 59 88 287 1 Yes 33 31 112 0.93 0.53, 1.5 p = 0.616 Flatmates drink No† 47 28 42 1 Yes 42 81 339 4.9 2.3, 10.4 p = 0.003 Smoker Never† 88 112 303 1 Former 3 2 54 7.1 2.7, 19.1 p = 0.004 Current 0 1 34 22.4 1.8, 278.3 p = 0.025 † Reference category; *OR = odds-ratio adjusted for cluster sampling approach comparing combined abstainers and ex-drinkers with drinkers; **95%-CI = 95%-confidence interval. Numbers in table might not add up because of missing values.

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MEDICAL STUDENTS

33

Multivariate logistic regression analysis showed that male students were 4.5 times

(95%-CI = [2.1, 9.5]) more likely to be current drinkers than female students

(p=0.003). Students who reported that their family members never drank alcohol (OR

= 0.12; 95%-CI = [0.02, 0.76]; p=0.032) or were drinking alcohol less frequently than

once per month (OR = 0.63; 95%-CI = [0.39, 1.0]; p=0.052) were less likely to be

current drinkers than students whose family members drank alcohol more frequently.

Students who reported that their flat mates were drinking alcohol were 2.6 times

(95%-CI = [1.5, 4.5]; p=0.008) more likely to be current drinkers. These models were

adjusted for the confounding effects of age, ethnicity and smoking habits of the

students and for the cluster sampling approach.

2.3.2. Alcohol problems and associated factors Overall, 73 students (12.5%) were identified with an AUDIT score of ≥8 (Table 2).

Males were considerably more likely than females to show alcohol problems

(OR=23.3; 95%-CI= [6.5, 84.2]). Older age (OR= 2.4; 95%-CI= [1.3, 4.6]), flat mates

drinking (OR=9.9; 95%-CI= [1.8, 55.3]) and current smoking (OR=7.0; 95%-CI= [3.1,

15.8]) were also associated with experiencing alcohol problems (Table 2.2).

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34

Table 2.2: Associations between the categorised AUDIT screening tool and social and demographic factors in a sample of 586 medical students (two universities). An AUDIT score of 0 to 7 implies

alcohol intake without alcohol problems; and AUDIT score of 8 or greater implies alcohol problems. AUDIT score 0

n=158 1-‐7

n=355 >= 8 n=73

OR* 95%-‐CI**

p-‐value

Gender Female† 135 160 4 1 Male 23 195 69 23.3 6.5, 84.2 p = 0.001 Age group =22 years 64 206 53 2.4 1.3, 4.6 p = 0.017 Ethnicity Kinh† 132 295 57 1 Other 19 46 10 1.2 0.38, 3.5 p = 0.758 Major GP† 137 325 68 1 Traditional MD 21 29 5 0.68 0.23, 2.0 p = 0.399 Living (home area) City or town† 100 195 37 1 Lowland 38 91 19 1.2 0.66, 2.1 p = 0.506 Mountain 17 59 13 1.4 0.79, 2.4 p = 0.207 Other 2 9 4 2.9 1.3, 6.4 p = 0.018 Other studies No† 127 283 62 1 Yes 28 69 11 0.75 0.31, 1.8 p = 0.443 Part-‐time job No† 136 308 62 1 Yes 19 44 10 1.1 0.27, 4.7 p = 0.827 Father’s education ≤ Primary education 4 17 5 1.6 0.47, 5.5 p = 0.364 Secondary education 35 91 16 0.86 0.59, 1.2 p = 0.344 High school 53 110 22 0.91 0.41, 2.0 p = 0.784 Post high school† 66 137 30 1 Mother’s education ≤ Primary education 10 33 7 1.3 0.37, 4.5 p = 0.610 Secondary education 41 87 18 1.1 0.36, 3.5 p = 0.799 High school 43 105 23 1.2 0.50, 3.1 p = 0.567 Post high school† 62 130 24 1 Family members drink Never 11 3 0 na na na < once a month 33 76 11 0.63 0.23, 1.8 p = 0.301 ≥ once a month† 114 274 62 1 Live with family No† 104 255 57 1 Yes 54 99 16 0.66 0.32, 1.4 p = 0.202 Flat mates drink No† 60 48 2 1 Yes 86 290 69 9.9 1.8, 55.3 p = 0.019 Smoker Never† 152 287 42 1 Former 3 38 15 3.8 1.5, 9.6 p = 0.014 Current 0 21 14 7.0 3.1, 15.8 P = 0.002 † Reference category; *OR = odds-‐ratio adjusted for cluster sampling approach comparing combined students with AUDIT score 0 and 1 to 7 with students who had an AUDIT score of 8 or greater; **95%-‐CI = 95%-‐confidence interval. Numbers in table might not add up because of missing values.

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36

Multivariate logistic regression analysis showed that male students were 14.3 times

more likely to have an AUDIT score of ≥8 compared with female students (95%-CI=

[3.5, 58.2]; p=0.005). No significant associations were found between any other

social-demographic variables and alcohol problems (data not shown). Analyses were

adjusted for the confounding effects of smoking and drinking habits of flat mates and

for the cluster sampling approach.

2.4. Discussion Alcohol consumption prevalence among medical students found in this study is much

higher than that among the young Vietnamese population. Nationally, among youth

aged from 15 to 24 years asked in 2001 and 2002, less than 1% of females and around

20% of males reported ever drinking (Ministry of Health & General Statistic Office,

2003). Among 579 youth aged 18 to 24 in 2003, 80% reported they were lifetime

abstainers (WHO, 2004a).

Alcohol consumption in this study is as high as it is among medical students in Hong

Kong (Griffiths et al., 2006). The prevalence of alcohol problems, however, was lower

than that found in western countries such as Hungary (33%) (Varga & Buris, 1994)

and the United Kingdom (52%) (Granville-Chapman et al., 2001). This is consistent

with the general pattern of developing countries having lower rates of alcohol

consumption and problems than developed countries (WHO, 2005).

Gender strongly predicted alcohol consumption and problems. This finding is

consistent with other studies (Griffiths et al., 2006; Kjobli et al., 2004). The national

prevalence of heavy episodic drinking (at least five standard drinks at least once a

week) among young males (aged 18-24 years) was 8.1%. Among young females it

has been shown to be very rare (0%) (WHO, 2004b). Studies in other societies show

varying degrees of gender differences in hazardous drinking. Hazardous drinking is

around five times more likely in male medical students in Norway (Tyssen et al.,

1998) and binge drinking around three times more likely in male students in Hong

Kong (Griffiths et al., 2006), while gender did not predict binge drinking behavior in a

study of German medical students (Keller et al., 2007). Vietnamese social and cultural

norms for males and females probably underpin the strong gender differences

identified.

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38

(0.097 US dollars/gm pure alcohol) (WHO, 2004b). In Vietnam too, beer is more

expensive than wine, especially home brewed wine. Liquor regulation is weak in

Vietnam with a license to sell spirits required but not to sell beer and wine (WHO,

2004b). There is no quality control and checking of ethanol concentration in home

brewed wine. Further studies are required to examine the impact of the consumption

of unregulated alcohol on the occurrence of alcohol problems in medical students and

the Vietnamese population.

Study limitations

Since alcohol abuse can create strong social stigma, especially among women, and

because this study included ex-drinkers who might not report reliably alcohol

consumption, it is possible that alcohol consumption was generally under-reported.

For women, the Vietnamese version of the AUDIT instrument may not be a valid tool

for assessing alcohol problems (Kim Bao Giang et al., 2005) and an AUDIT score of

≥8 may not be a suitable cutoff. Other studies have used the lower cut-off point

(AUDIT ≥5) to detect alcohol problems among women (Adewuya, 2005; Neumann et

al., 2004). The study design was cross-sectional and therefore the study was only able

to investigate associations rather than causal links.

Conclusions

Alcohol consumption and problems are common amongst Vietnamese medical

students. Alcohol consumption was related to gender and the social context of the

students. Male students were most likely to consume alcohol and develop alcohol

problems. Targeted interventions to address alcohol problems in male students should

take their social environment into account. As Vietnamese society changes and

economy has grown rapidly in recent years, alcohol consumption has also increased

per capital from about 0.8 liters in 1989 to about 1.4 liters per year in 2001 in people

aged 15 years or older (WHO, 2002). Alcohol consumption and problems may also

increase among medical students, including female students. Hence it may be

necessary to focus on female and male in future primary prevention campaigns at the

community based and school based levels.

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MEDICAL STUDENTS

39

Given the limitation of the study, further research using qualitative and quantitative

approaches should investigate patterns of alcohol consumption and drinking behaviors

among other health care professional in this training setting for a wider understanding.

.

3. ALCOHOL-‐RELATED HARM AMONG UNIVERSITY STUDENTS IN HANOI, VIETNAM

42

Abstract: Introduction and Aim: This study examines the prevalence of and risk factors for

alcohol-related harm and types of harm among medical students from Hanoi Medical

University (Vietnam). Risk factors include aspects of drinking patterns and relevant

socio-demographic variables.

Study Design and Methods: A cross-sectional study involving 1st to 6th year

students (N =1216; response rate 96.5%). Of these, 210 students from each academic

year were randomly selected from a sampling frame covering all students from each

academic year. Data were collected using a questionnaire distributed in class by

researchers. Drinkers completed 23 questions on alcohol-related harm categorized

into: 1) ‘negative influence on daily activities’; 2) ‘social conflict’; 3) ‘loss of control,

acute consequences, and withdrawal’; 4) ‘mental health conditions’; and 5) ‘physical

and medical health problems’. Logistic and Poisson regression models were used to

identify the predictors of alcohol-related harm and the amount of harm, respectively.

Results: The prevalence of alcohol use associated with at least one or more of the five

types of harm was higher in men (81.8%) than in women (60.4%). In female and male

students, the most common harm category was ‘loss of control, acute consequences,

and withdrawal’ (51.8 and 75.6%, respectively), followed by ‘negative influence on

daily activities’ (29.4 and 55.8%, respectively). Age, living away from home, and

average number of standard drinks per occasion among male drinkers, and age and

frequency of drinking per week among female drinkers were associated with alcohol-

related harm.

Conclusions: These data suggest that alcohol-related harm represents a serious public

health problem among young educated individuals in Vietnam. The risk factors

indicate that prevention should be aimed at aspects of drinking patterns and specific

subpopulations defined by gender, age, and (for men only) type of living situation.

Keywords: female students; male students; alcohol-related harm; type of harm;

drinking patterns; Vietnam

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43

3.1. Introduction Alcohol is the third leading cause of burden of disease worldwide. It is reported that of

all deaths among young people aged 15-29 years, 9% is related to alcohol (WHO,

2011a). Harmful drinking patterns, such as binge drinking (mostly defined as drinking

≥ 6 glasses on one occasion), have increased among young adults and adolescents

(WHO, 2007). Harmful drinking is also popular among college students (Kypros

Kypri et al., 2009; Wechsler, Davenport, Dowdall, Moeykens, & Castillo, 1994). A

study among Vietnamese medical students indicated that the prevalence of alcohol

consumption (65.5%) and alcohol-related problems (12.5%) is relatively high (D. B.

Pham, Clough, Nguyen, Kim, & Buettner, 2010); however, data on the negative

consequences of harmful drinking in this population are scarce .

Regarding alcohol-related harm, the prevalence of negative consequences of alcohol

use is high in both male and female students in developed countries such as New

Zealand and the USA (Kypros Kypri et al., 2009; Crystal L Park, 2004). After

drinking, male and female students often experience blackouts,

unintended/unprotected sexual activity, academic impairment, short and long-term

physical illness and poor mental health, as well as anti-social risk behavior, fights and

interpersonal violence (Best et al., 2006; Bullock, 2004; C. J. Cronin, 1991; Crystal L.

Park & Grant, 2005; Perkins, 2002). A study among young Australian students

suggested that alcohol-related harm has increased dramatically in recent years

(Livingston, 2008); however, studies on alcohol-related harm among students in

developing countries are still scarce. A study in Thailand also indicated that the

prevalence of hangover, nausea and vomiting among adolescent drinkers is high

(46.9%) (Sawitri Assanangkornchai, Anocha Mukthong, & Tanomsri Intanont, 2009);

however, information on alcohol-related harm among students in Vietnam is lacking.

Two studies among adolescents/young adults in Vietnam examined the association

between alcohol use and sexual behavior only; the results show a strong link between

alcohol consumption and engaging in sexual behavior among both males and females

(L M Kaljee et al., 2005; Tho, Singhasivanon, Kaewkungwal, Kaljee, & Charoenkul,

2007).

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44

Drinking patterns, in addition to quantity, are strongly related to harm. The volume of

consumption (mostly expressed as the number of standard drinks per week or month)

is an important determinant of alcohol-related harm (Jürgen Rehm et al., 2010; Jurgen

Rehm et al., 2003). Nevertheless, the same volume can still conceal very different

drinking patterns. The aspect of drinking patterns most widely examined is that of

binge drinking. Other measures for incidental high consumption, such as the greatest

number of glasses consumed on one occasions and frequency of drunkenness, are also

related to an increased risk for harm. A national survey of students at 140 campuses in

the USA showed that frequent binge drinkers and infrequent binge drinkers were 25

and 5 times, respectively, more likely to have experienced at least five harms

compared to non binge drinkers (Wechsler et al., 1994). Notably, students who drink

both heavily and frequently experienced negative consequences almost three times as

often as those who drink heavily and less often (Presley & Pimentel, 2006).

Socio-demographic factors (such as age and gender) are also associated with alcohol-

related harm. A study in the UK showed that older adolescents are more likely to

report alcohol-related violence and alcohol-related regretted sex (Bellis et al., 2009).

Many studies in developed countries (e.g. USA, New Zealand, Australia, Sweden,

Germany) and in developing countries (e.g. Thailand and China) report a gender

difference in drinking patterns that influence harms (Sawitri Assanangkornchai et al.,

2009; Bendtsen, T, & Kerlind, 2006; Caitlin, Beau, & Rob, 2009; Clement, 1999;

Keller et al., 2007; Kypri, Paschall, Langleyb, Baxterd, & Bourdeau, 2010; McBride,

Farringdon, & Midford, 2000; White, Jamieson-Drake, & Swartzwelder, 2002; Xing,

Ji, & Zhang, 2006). Similarly, a study among students in Vietnam reported that men

were 14.3 times more likely to have alcohol problems compared with women (D. B.

Pham et al., 2010).

The present study among Vietnamese students addresses three related questions: 1)

What is the prevalence of alcohol-related harm in this group? 2) How are socio-

demographic variables and drinking patterns associated with alcohol-related harm?

and 3) Do socio-demographic and drinking pattern variables explain the variation in

the number of alcohol-related harms that students report?

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45

3.2. Methods 3.2.1. Setting A cross-sectional study was conducted between November 2008 and January 2009 at

Hanoi Medical University (the oldest and largest medical university in Hanoi,

Vietnam).

3.2.2. Sample size and sampling Within each academic year, the World Health Organization sample size calculation

was applied to calculate a sample size, assuming a 45% prevalence of alcohol-related

harms among drinkers (with a precision of ± 0.2 and a 95% confidence level). Since

we cannot select drinkers, the sample size required is calculated based on the

prevalence of alcohol use among students, i.e. 65% (5); therefore, a sample size of 180

students per academic year was needed. This number was increased by 5% to account

for losses and by an additional 10% to control for confounding, yielding a sample size

of 207 students for each academic year (rounded up to 210 students per academic

year). The total sample size of 1260 students was also sufficient to achieve 90%

power to detect an absolute difference of 15% in the proportions of having alcohol-

related harm among male and female students (level of significant of 5%, and non-

response-rate and confounding control of 15%). Then, 210 students per academic year

was randomly selected from the register of medical students for each academic year

(provided by the Dept. of Training and Education at Hanoi Medical University). At

this stage, a total of 1260 university students from the 1st to 6th study years were

selected. Finally, 1216 students (96.5%) participated in the study; 44 students (3.5%)

declined to participate. The age and sex distribution of the non-respondents did not

differ from that of the respondents.

3.2.3. Data collection A letter explaining the aims, assurance of confidentiality, and specification of the date,

time and place to fill in the questionnaire, was delivered to the selected students by

their class monitors. The investigators and research assistants were trained before data

collection.

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46

Each time point of data collection involved a maximum of 30 students, 1 investigator

and 2 research assistants. The structured questionnaire and pictures of the most

common beverages in Vietnam (with their ethanol levels, and corresponding units for

a standard drink) were distributed to the students by the research assistants. The

investigators explained the definition of a standard drink (SD) used for this study (see

Measures below) and instructed students on how to fill in the questionnaire. In

addition, the students were assured of their right to withdraw from the study at any

time and for any reason. If a student had any query related to the questions, the

investigator provided clarification. After the questionnaire was completed it was

handed to the investigator.

3.2.4. Questionnaire The questionnaires were newly developed to measure alcohol-related harms based on

literature and experts’ opinions. First, the questionnaire was pre-tested among 20

students at Hanoi Medical University to ensure that they clearly understood the

meaning of all the questions.

The questionnaire was divided into two parts.

The first part included questions on demographics (age, gender, type of living

situation, and academic year level) and on drinking patterns. For example: “How often

did you drink at least one full SD of alcohol in the previous 12 months?” and “How

often did you drink at least four SDs (for females) or five SDs (for males) per occasion

in the previous 12 months”.

Responses were made on a 7-point scale: 0 = never (recoded to 0); 1 = almost daily

(recoded to 7); 2 = 3-4 days per week (recoded to 3.5); 3 = 1-2 days per week (recoded

to 1.5); 4 = 1-2 days per month (recoded to 0.375); 5 = once per month (recoded to

0.25); and 6 = less than once per month (recoded to 0.125). Midpoints of categories

were used for the recoding (Kuntsche et al., 2007; Offerman, Kuntsche, & E&Knibbe,

2011). To gain more insight into drinking patterns, questions were also asked about

“How many SDs did you on average consume per occasion?” and “What is the highest

number of SDs you have ever consumed in the previous 12 months?”. These types of

answers were coded as the actual numbers of SDs consumed.

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47

The second part of the questionnaire included 23 possible alcohol-related harms (see

Appendix 3.1), categorized into 5 main types of harm (see appendix); these were

developed from the literature and based on the opinions of experts. For the present

study, a set of items within each of the 5 types of harm was tested for internal

consistency (Cronbach’s alpha). The 5 types of harm are: ‘negative influence on daily

activities’ (Cronbach’s alpha = 0.78); ‘social conflict’ (Cronbach’s alpha = 0.67); ‘loss

of control, acute consequences and withdrawal’ (Cronbach’s alpha = 0.70); ‘mental

health condition and physical illness’ (Cronbach’s alpha = 0.51); and ‘medical health

problems’ (Cronbach’s alpha = 0.53).

In the first four types of harm, respondents were asked to rate the number of harms

experienced during the previous 12 months on a 4-point scale (0 = never; 1 = one

time; 2 = two times; 3 = at least three times). For the fifth type (‘medical health

problems’), respondents were asked whether they had experienced these harms (0 = no

and 1 = yes) during the previous 12 months. The response to each type of harm is the

sum of the positive answers to each of the items indicating that type of harm. For the

logistic regression, the sum score was computed by recoding each type of harm into

two categories: 0 = never and 1 = yes. In this way the sum score indicates the variety

of different harms experienced by the respondent.

3.2.5. Measures For the present study a standard drink (SD) = 1 can of beer (330 ml at 5%) = 1 glass of

wine (140 ml at 12%) = 1 shot of spirit (40 ml at 40%) = 12.6 g of pure alcohol.

Abstainers are students who reported not to drink at least one full SD of alcohol in the

previous 12 months. Drinkers are students who reported to drink at least one full SD

of alcohol in the previous 12 months. Binge drinkers are students who reported to

drink at least 4 SDs (for females) or 5 SDs (for males) per occasion in the previous 12

months.

3.2.6. Data analysis Analyses were performed with SPSS for Windows (version 15) and STATA (version

10). Cronbach’s alpha was calculated to establish the internal consistency of the

.


48

scales. Descriptive statistics were used to detect differences between male and female

students. All other analyses were performed for males and females separately.

Descriptive statistics were used to estimate the frequency and prevalence of alcohol-

related harm. Intercorrelations between potential predictors in the multivariate analysis

were low (r < 0.3), except those between the ‘maximum number of SD consumed’ and

the ‘average number of SD consumed’ (r = 0.53). Logistic regression was used to

compare the drinkers without alcohol-related harm and those with at least one type of

harm. Independent variables were entered in two steps: 1) age and type of living

situation, and 2) drinking pattern variables. This allowed to assess the predictive

ability of the drinking pattern variables while controlling for the effects of variables in

step 1. In turn, the dependent variables representing the 5 types of harms were entered

separately into the model. Results were presented as odds ratios (OR) with 95%

confidence intervals (95% CI).

Then, poisson regression analyses were conducted to investigate relationships between

age, type of living situation, drinking pattern variables and number of harms. The

number of harms is calculated by summing up how many of the 5 types of harms the

students scored positively (score 0-5). In all multivariate analyses, unweighted data

were used.

3.3. Results The sample population (n=1216) included a similar number of female (n=606; mean

age 20.8 years) and male students (610; mean age 20.6 years). Regarding living

situation, more male than female students lived in a rented house, whereas more

female than male students lived in a dormitory or with a family. Male students were

twice as likely to be drinkers than female students (Table 3.1).

.


49

Table 3.1: Socio-demographic and drinking behavior characteristics of 1216

medical students in the survey at Hanoi Medical University.

Variables Females (n=606)

Males (n=610)

p-value Total (n=1216)

Age in years: mean (range)

20.8 (17-26) 20.6 (18-28) >0.05 20.7 (17-28)

Academic year (%) First year 13.5 20.7


50

Table 3.2: Drinking patterns and number of harms by gender in a sample of 699

drinkers in the survey at Hanoi Medical University. Variables Females (n=227)

Median [IQR] Males (n=466) Median [IQR]

p-value Total (n=699) Median [IQR]

1. Drinking pattern 1.1. Frequency of drinking

0.125[0.125; 0.125]

0.25 [0.125; 0.375]


51

3.3.2. Association between specific factors and alcohol-related harm Among female drinkers, very few significant relations were found (Table 3.4). Only

the frequency of drinking per week and age were predictors of mental health condition

and physical illness. Female students who drank more frequently per week were about

6 times more likely to have experienced mental health conditions and physical

problems. The older female students less often experienced mental health conditions

and physical problems (Table 3.4).

.

3. ALCOH

OL-‐RELATED HARM AMON

G UN

IVERSITY STUDENTS IN HAN

OI, VIETNAM

52

Table 3.4: Alcohol-‐related harm among 228 female drinkers at Hanoi Medical University by socio-‐dem

ographics and drinking behavior

Model

Negative

influence on

daily

activities

Social conflict

Loss of

control

Mental health

condition and

physical

problem

Medical

health

problems

OR 95% CI OR 95% CI

OR

95% CI OR

95% CI

OR

95% CI

Model 1

Age

0.9

0.8-‐1.1

0.6

0.4-‐1.0

1.0

0.9-‐1.2

0.7**

0.6-‐0.9

0.9

0.7-‐1.1

Living situation:

Dormitory vs w

ith family

1.3

0.7-‐2.6

na

na

1.0

0.5-‐1.7

1.5

0.5-‐4.1

2.1

0.7-‐6.3

Rent house vs w

ith family

1.0

0.5-‐2.3

na

na

1.1

0.5-‐2.3

1.0

0.3-‐3.8

1.1

0.3-‐4.6

Model 2

Age

0.9

0.8-‐1.1

0.7* 0.5-‐0.9

1.0

0.5-‐2.4

0.7*** 0.5-‐0.8

0.9

0.7-‐1.1

Living situation:

Dormitory vs w

ith family

1.4

0.7-‐2.9

na

na

1.0

0.5-‐1.2

2.0

0.6-‐6.8

1.7

0.5-‐5.7

Rented house vs w

ith family

1.0

0.4-‐2.3

na

na

1.0

0.5-‐1.9

1.2

0.3-‐4.8

0.8

0.2-‐3.5

Frequency of drinking per w

eek

0.7

0.1-‐3.2

na

na

1.1

0.5-‐2.5

6.2*

1.2-‐33.6

na

na

Frequency of binge drinking per w

eek

1.9

0.9-‐4.1

na

na

0.0

0.0-‐3.4

0.6

0.2-‐1.4

na

na

Maximum

num

ber of SD consum

ed

1.1

1.0-‐1.3

1.1

0.9-‐1.6

1.1

1.0-‐1.3

1.1

1.0-‐1.3

1.1

0.9-‐1.5

Average number of SD consum

ed per

occasion

1.1

1.0-‐1.3

0.4

0.0-‐2.6

1.3

0.9-‐1.9

1.0

0.9-‐1.3

0.9

0.7-‐1.2

OR = odds ratio; CI = confidence interval; SD = standard drinks; *p<0.05; ** p

3. ALCOH

OL-‐RELATED HARM AMON

G UN

IVERSITY STUDENTS IN HAN

OI, VIETNAM

53

Table 3.5: Alcohol-‐related harm among 470 male drinkers at Hanoi Medical University by socio-‐dem

ographic and drinking behavior

Model

Negative

influence on daily

activities

Social conflict

Loss of control

Mental

health

condition

and physical

problem

Medical

health

problems

OR

95% CI

OR

95% CI

OR

95% CI

OR

95% CI OR 95% CI

Model 1

Age

1.20

*** 1.1-‐1.3

1.2** 1.1-‐1.4

1.2*

1.0-‐1.3

1.1* 1.0-‐1.3

1.1

1.0-‐1.3

Living situation:

Dormitory vs w

ith family

2.2**

1.3-‐3.7

1.2

0.6-‐2.7

2.4**

1.4-‐4.4

2.0* 1.1-‐3.6

0.9

0.4-‐1.9

Rented house vs w

ith family

1.9*

1.1-‐3.0

1.0

0.5-‐2.2

1.8*

1.0-‐3.0

1.9* 1.1-‐3.5

1.6

0.8-‐3.2

Model 2

Age

1.2**

1.0-‐1.3

1.2** 1.1-‐ 1.4

1.1*

1.0-‐1.3

1.1* 1.0-‐1.2

1.1

1.0-‐1.3

Living situation:

Dormitory vs w

ith family

2.1**

1.2-‐3.8

1.3

0.4-‐ 1.5

2.3**

1.3-‐4.2

2.0* 1.0-‐3.6

0.9

0.4-‐1.9

Rented house vs w

ith family

1.8*

1.1-‐3.0

1.1

0.3-‐1.7

1.7*

1.0-‐3.0

2.0* 1.1-‐3.6

1.6

0.8-‐3.1

Frequency of drinking per w

eek

1.0

0.7-‐1.4

1.3

1.0-‐ 1.8

1.0

0.6-‐1.7

1.2

0.9-‐1.5

1.1

0.8-‐ 1.6

Frequency of binge drinking per w

eek

4.3

0.1-‐248.1

1.3

0.9-‐ 1.7

2.1

0.1-‐ 29.4

1.2

0.9-‐1.8

1.1

0.8-‐1.6

Maximum

num

ber of SD consum

ed

1.0

0.9-‐1.1

1.0

1.0-‐1.0

1.0

0.9-‐1.1

1.0

1.0-‐1.1

1.0

1.0-‐1.1

Average number of SD consum

ed per

occasion

1.1*

1.1-‐1.2

1.0

1.0-‐1.1

1.1

0.9-‐1.3

1.0

1.0-‐1.1

1.1

1.0-‐1.1

OR = odds ratio; CI = confidence interval; SD = standard drinks; *p<0.05; ** p


54

Among male drinkers far more significant relations were found. Predictors of different

types of harms are: the average number of SD consumed per occasion, age, and type

of living situation. Among drinking variables, only ‘average number of SD consumed

per occasion’ was associated with a negative influence on ‘daily activities’ and

‘medical health problems’. Male students living in a dormitory or in a rented house

were more likely to have experienced a ‘negative influence on daily activities’,

‘mental health condition’ and ‘physical problems’ than those living with a family.

Only those living in a dormitory were more likely to experience ‘loss of control, acute

consequences, and withdrawal’. The older the male students, the more likely they

were to have experienced a ‘negative influence on daily activities’, ‘social conflict’,

‘loss of control, acute consequence and withdrawal’, ‘mental health condition’ and

‘physical/medical problems’ (Table 3.5). These findings suggest that the relations

between socio- demographic variables and harms were not explained by the drinking

pattern variables.

3.3.3. Association between specific factors and number of harms All drinkers who did not experience any harm and experienced at least one harm

included in the analysis. Table 3.6 showed that age was a significant predictor of the

number of harms among female drinkers while age, living away from home, average

number of standard drinks per occasion are significant predictors of the number of

harms among male drinkers.

.


55

Table 3.6: Poisson regression model for number of harms among 228 female and

470 male drinkers at Hanoi Medical University by socio-demographic and drinking

behavior

Model Female students Male students Coef 95% CI Coef 95% CI Model 1 Age -0.074* -0.15 - -0.01 0.07*** 0.03 - 0.10 Living situation:

Dormitory vs with family 0.16 -0.14 - 0.46 0.27** 0.08 - 0.45 Rented house vs with family 0.09 -0.25 - 0.45 0.23 0.05 - 0.41

Model 2 Age -0.09* -0.02 - -0.02 0.06** 0.03 - 0.09 Living situation:

Dormitory vs with family 0.21 -0.11 - 0.52 0.25** 0.06 - 0.44 Rented house vs with family 0.04 -0.33 - 0.41 0.23* 0.05 - 0.41

Frequency of drinking per week 0.16 -0.05 - 0.82 0.06 -0.04- 0.15 Frequency of binge drinking per week

0.02 -0.19 - 0.23 0.08 0.01 - 0.17

Maximum number of SD consumed

0.04 -0.00 - 0.09 0.01 -0.00 - 0.02

Average number of SD consumed per occasion

0.05* -0.01 - 0.11 0.02* 0.01 - 0.03

CI = confidence interval; SD = standard drinks; *p


56

students in Australia being sick (12.8%), hangovers (12.3%), and being unable to

remember what happened after drinking (10.4%) (McBride et al., 2000). A study

among adolescents in Thailand also indicated that the negative consequences were

nausea and vomiting (46.9%), being criticized by someone (38.8%), hangover

(37.8%), driving a car or motorcycle after drinking (35.4%), and missing class

(32.8%) (Sawitri Assanangkornchai et al., 2009).

In the present study, the prevalence of harm is higher compared with other studies.

However, it is difficult to compare the prevalence of alcohol-related harm between

studies due to the different measures used. For example, in many studies, each type of

harm generally includes only one item whereas in our study each type of harm

included 2-7 items of harm. This means that students in the present study who

experienced 1 out of 2-7 items of harm were considered to have alcohol-related harm,

leading to a higher prevalence of harm. A Swedish study used a similar measure of

collecting data over 12 months and categorized harms into five types (Bullock, 2004).

This resulted in a prevalence of 43% of having at least one harm, which is lower than

that in Vietnam. Moreover, compared with our students, the prevalence of each type of

harm in the Swedish study was also lower, i.e. 1) physical health (25.1%): 2) financial

situation (12.9%); 3) study or work life (5.5%); 4) family life, marriage or relationship

(1.5%

alcohol consumption among students in vietnam - caphri · 2016-06-13 · in fact, patterns of...

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