Alcohol drinking patterns among high school students in Ethiopia: a cross-sectional study

There is global concern about drinking trends among young people. Alcohol consumption is an important risk factor for morbidity, mortality and social harm worldwide [1–3] leading to 2.5 million deaths each year [4]. It is responsible for approximately 4% of the global burden of disease. This burden is higher in high income countries and among men, accounting for 11% of all male deaths in the World Health Organization (WHO) European region in 2004 [2]. Even though the problem is said to be increasing in the developing world, there are no sufficient data on alcohol use and its consequences in many developing countries [4, 5].

The use of alcohol during the teenage and young adulthood years is a common phenomenon in many societies. For large numbers of youth it may signify psychological experimentation and risk taking [6]. Epidemiological studies indicate that a substantial proportion of alcohol users progress to problematic drinking or become alcohol dependent [7]. Alcohol consumption at a young age increases the risk of developing alcohol related problems later in life [8–11]. Among youth, drinking often coexists with other problem behaviors such as poor academic performance [12] and absenteeism [13] which may impair healthy development and successful transition from adolescence to adulthood [14].

A study conducted among high school adolescents in Ethiopia from 2001 to 2002 reported that about 8.9% drunk alcohol at least on a weekly bases [15], where as other reports among students in southern Ethiopia and a private school in Addis Ababa found a prevalence of 57.7% and 19.2% respectively [5]. In other sub-Saharan African countries like Kenya ever drinking prevalence of up to 15% were found among secondary school students [16], where some private universities had rates as high as 84% [17]. A study from South Africa also reported an alcohol use prevalence of 39.1% among high school adolescents [18].

As in other developing countries, the distribution and consumption of substances including alcohol are not sufficiently studied in Ethiopia [5, 19]. Alcohol consumption is not legally prohibited in Ethiopia and there are no age limits on alcohol drinking [19]. Culturally, it is consumed in social gatherings and among friends as a pass time activity and relaxation experience [19]. Description of the relationship between alcohol use and other important variables would usefully guide national policy and decision making on consumption patterns and how its impact could be mitigated. The main aim of this study was to determine the prevalence and factors associated with alcohol use among high school students in eastern Ethiopia.

There is a growing concern regarding the increase in preventable harms attributed to adolescent alcohol consumption [23]. Such concern has prompted medical and research debate regarding the delaying of adolescent alcohol consumption for as long as possible [7, 8, 24]. This study tried to investigate alcohol use among high school adolescents in eastern Ethiopia.

The findings indicate an alcohol use prevalence of 22.2% (95% CI 20.2 - 24.2%) among the sampled high school students. About 10% (95% CI 9.0-11.8%) have drank in the past 30 days. We have also identified that male gender (OR 2.09; 95% CI 1.45-3.00), older age (OR 1.16; 95% CI 1.01-1.34), having friends who drink alcohol (OR 10.09; 95% CI 6.84-14.89) or living with people who use alcohol (OR 2.77; 95% CI 1.89-4.07) as strong predictors of drinking among the students.

Our finding of ever and past month alcohol drinking of 22.2% and 10.4% respectively seem to be lower than the report from Addis Ababa which indicated alcohol drinking prevalence of 45.7% and 26.5% in the same order [25]. The main explanation for this is probably that Harar town is more cultural and value oriented than those studied in Addis Ababa. Also the fact that there is less exposure to alcohol advertising compared to Addis Ababa where billboards and FM radio advertisements are abound and could contribute to the lower drinking level in this study [26, 27]. It is also lower than 41.8% past 30 days drinking by high school students in the USA [28] and 51.9% ever-drinking prevalence of alcohol use reported among secondary school students in Kisumu town, Kenya [29]. Similarly, a South African study reported an alcohol use prevalence of 39.1% among high school adolescents [18]. Other studies among high school students in Africa also report similar finding of a high prevalence rates of alcohol use, ranging from 15% to 57.9% [16, 18, 30]. The primary reason for the comparatively lower alcohol drinking level in this study could be lack of access due to cultural and economic reasons. Despite this, the level of drinking in this study is far from normal and should be a cause for concern as it is a dangerous precedent for other risky behaviors both during adolescence and in adult life [24]. Already, 30 percent of ever drinkers have also smoked a cigarette. Furthermore there are no assurances that the observed level of drinking could not progress to high levels of drinking over time and multi-substance use.

In this study, the average age at which the respondents started using alcohol was 17.5 years. On average, both sexes seem to start drinking beyond the high risk age of 14 years, which is associated with high risk for alcohol abuse and dependence in later life according to studies on sample populations from the USA [24]. However, a recent systematic review indicates that later adolescence drinking could progress into late adulthood drinking habits, and it was also associated with suicide, car crashes and mental and social problems [31]. Currently, a legal age limit for drinking as well as other important ordinances that ban drinking in certain places and advertising that tempt adolescents do not exist in the country, probably indicating the little attention given to adolescent drinking [19]. This is understandable given the infectious disease focus of health authorities in developing countries.

Our findings indicate that males have higher odds of drinking than females (2.09; 95% CI 1.45-3.00). This is a common finding in substance use studies where males use substances more and show higher tendency for dependence than females. Apart from measurement and reporting issues [32, 33], it could mainly be explained by higher exposure opportunities due to reasons such as psychological, family and social factors [32, 34, 35]. The findings also indicate that having friends who drink alcohol and living with people who drink alcohol are very strong predictors of alcohol use among the sample studied. This is in line with the consistent findings in the literature concerning peer pressure, influence of social groups and the suggestibility of adolescents toward alcohol drinking as well as other substances [7, 36–38]. Hence, this calls for awareness campaigns that have more focus on social groups and peers.

This study has limitations. One of them is the use of self-reporting methods. Self-reporting is prone to recall bias and under reporting due to social desirability bias. As a result the reported data are most likely an underestimation of true levels of drinking. However, we could not also exclude the possibility of exaggeration [39]. The other important consideration is that non-respondents might have higher levels of drinking compared to respondents. This is because one of the reasons of non-response in this study is absence from class which could be due to substance related delinquency. Furthermore, close to half of the sample is composed of ninth graders. The trend of decreasing student numbers in subsequent classes might be due to a range of underlying factors influencing school attendance, the role of risk behaviors such as substance use cannot be ruled out.

In conclusion, our findings indicate that there are high levels of alcohol drinking among the sampled high school students. Parents, as well as school and health authorities need to work more toward awareness creation about the hazards of alcohol drinking. We also call upon policy makers to put in place ordinances for adolescent drinking.