This KAP survey reflects and builds on existing STEPS findings, confirming high levels of alcohol consumption in Mongolia. Indeed, up to 80% of urban Mongolian men were found to have consumed alcohol in the previous year, compared to 70% and 20% of men in China and India respectively [9, 23]. Contrasting the rural and urban settings, alcohol consumption was higher among urban dwellers, with up to twice as many drinkers as compared to the rural population. This finding could support previous research suggesting that high alcohol intake is linked to social and epidemiological transition processes, such as urbanisation . It could be inferred that as Mongolians become wealthier, more urbanized and have continuous access to alcohol, consumption rises.
Applying the findings of this research to Public Health practice, three clear populations with distinct health risks and needs emerge: rural Mongolian men; urban Mongolians; and young Mongolians (Additional file 10: Table S10).
This national KAPS survey revealed a high level of health knowledge, particularly among urban participants, regarding the risks of daily alcohol consumption and awareness about the heavy episodic drinking prevalence in Mongolia. This is also the group with the highest prevalence of such behaviours. Combined, these findings support the notion that high levels of awareness alone may have little impact on healthy-behavioural outcomes in a population, findings which are echoed in other populations globally . In addition, drink driving was common among Mongolian car-owners, more than 70% of which live in urban settings. Indeed, among current drinkers, 15% reported to have driven while influenced by alcohol; a figure approximately four times the level of the USA . For Mongolia, where road-traffic accidents are now the fourth-leading cause of mortality, this represents a large but modifiable potential contributor to public risk.
These findings support the need for legislative policy responses such as harsher blood alcohol concentration laws, closer enforcement of such laws including sobriety checkpoints, and limitations to access for alcohol, rather than solely education or public awareness campaigns in urban Mongolia [1, 2, 25, 26].
Findings also show that urban drinking was associated with celebrations and social events. In the context of the rapid urbanisation as well as the increasing Western-style branding and marketing of alcohol in recent decades, this may represent a changing social paradigm around drinking, where advertising and marketing of alcohol promote its association with festivities and celebrations, leading to higher levels of alcohol consumption in such settings. If identified as a threat to public health in Mongolia, this association may indicate the need for more stringent regulation of alcohol advertising as is seen in other nations [27, 28].
In contrast, rural participants were less aware of heavy episodic drinking as a national health issue and of the risks posed by drinking. While reporting a lower drinking prevalence, higher levels of dangerous drinking behaviours were reported. These findings were particularly evident among men. This echoes similar studies from China and India, where risky alcohol consumption is also linked to male-gender and rural dwelling [29, 30]. Morning drinking more specifically was associated with male-gender and rurality in Mongolia, with up to one in three rural men reporting morning drinking in the last month as current drinkers of alcohol. Although these findings may represent long-standing traditional practices in Mongolia, such as home brewing of alcohol, they also likely highlight particular health-knowledge gaps requiring targeted public health responses in rural areas. This may see regulatory, harm-reduction efforts combined with culturally-sensitive educational campaigns [14, 31, 32] (Additional file 10: Table S10).
Looking across the lifespan, low youth drinking rates with a peak in the late-twenties suggests that most Mongolians begin consuming alcohol during their second decade of life, a practice that peaks in middle-age. This is in contrast to many developed nations, where drinking uptake usually peaks in the teenage years [33–35], and it may help to identify a wider window of opportunity for public health efforts, for which earlier interventions are generally more effective. Such measures may include school-based harm-minimisation programs, as well as pricing and advertising regulations [26, 36].
Finally, findings reveal that drinking and heavy drinking were less common among the oldest Mongolians. As alcohol in some form has been part of the Mongolian culture for many centuries, this supports the theory that the high burden of drinking in early-middle age may not be linked to the long-standing Mongolian cultural norms. Instead, a new practice, possibly associated with rapid recent socio-economic changes and urbanisation in Mongolia , might justify these findings. If such is true, this again supports the need for swift and meaningful public health responses as earlier outlined.