Gary C.K. Chan, PhD,1 Adrian B. Kelly, PhD,1 Jason P. Connor, PhD,1,2. Wayne Hall, PhD,1 Ross McD. Young, PhD,3 John W. Toumbourou, PhD. 4,5 and.
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Aust. J. Rural Health (2016) 24, 3–8
Original Research Regional versus urban differences in teenage alcohol use: Does parental disapproval account for these differences? Gary C.K. Chan, PhD,1 Adrian B. Kelly, PhD,1 Jason P. Connor, PhD,1,2 Wayne Hall, PhD,1 Ross McD. Young, PhD,3 John W. Toumbourou, PhD4,5 and Joanne Williams, PhD5,6 1
Centre for Youth Substance Abuse Research, The University of Queensland, 2Discipline of Psychiatry, School of Medicine, The University of Queensland, 3Faculty of Health, Queensland University of Technology, Brisbane, Queensland, 4School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 5Centre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia and 6School of Health and Social Development, Deakin University
Abstract Objective: To investigate if parental disapproval of alcohol use accounts for differences in adolescent alcohol use across regional and urban communities. Design: Secondary data analysis of grade-level stratified data from a random sample of schools. Setting: High schools in Victoria, Australia. Participants: A random sample of 10 273 adolescents from Grade 7 (mean age = 12.51 years), 9 (14.46 years) and 11 (16.42 years). Main outcome measures: The key independent variables were parental disapproval of adolescent alcohol use and regionality (regional/ urban), and the dependent variable was past 30 days alcohol use. Results: After adjusting for potential confounders, adolescents in regional areas were more likely to use alcohol in the past 30 days (OR = 1.83, 1.44 and 1.37 for Grades 7, 9 and 11, respectively, P < 0.05), and their parents have a lower level of disapproval of their alcohol use (b = −0.12, −0.15 and −0.19 for Grades 7, 9 and 11, respectively, P < 0.001). Bootstrapping analyses suggested that 8.37%, 23.30% and 39.22% of the effect of regionality on adolescent alcohol use was mediated
by parental disapproval of alcohol use for Grades 7, 9 and 11 participants respectively (P < 0.05). Conclusions: Adolescents in urban areas had a lower risk of alcohol use compared with their regional counterparts, and differences in parental disapproval of alcohol use contributed to this difference. KEY WORDS: adolescence, adolescent, alcohol, parental disapproval, regional, urban.
Introduction
Accepted for publication 5 January 2015.
Alcohol use is commonly initiated during early to midadolescence. Alcohol use and misuse among adolescents is common and results in significant public health costs in Australia and internationally.1 In Australia, 20.1% of individuals aged 14+ years have consumed alcohol at risky levels, and 28.4% have engaged in regular heavy episodic drinking (five or more standard drinks in a single occasion).2 To reduce alcohol-related harm in adolescents, the Australian National Health and Medical Research Council (NHMRC)3 has recommended that (i) children under 15 years of age should be discouraged from drinking any alcohol, and (ii) young people aged 15–17 years should delay the initiation of drinking for as long as possible. Available research indicates that alcohol misuse and alcohol-related harm are more common in regional than urban areas in Australia.4 In the overall population, the prevalence of risky drinking was 16.7% in major cities and 35% in remote areas.2 Among young adult populations, those living in regional areas were more likely to engage in high-risk drinking compared with their urban counterparts.5 The higher prevalence of risky alcohol use in regional and rural areas translates into higher rates of alcohol-related hospitalisation6 and alcohol-related mortality.7 While regional and urban differences in risky
© 2015 National Rural Health Alliance Inc.
doi: 10.1111/ajr.12177
Correspondence: Dr Gary C.K. Chan, Centre for Youth Substance Abuse Research, The University of Queensland, Brisbane, Queensland, 4072, Australia. Email: c.chan4 @uq.edu.au Declaration: The authors declare that the material has not been published in whole or in part elsewhere, the paper is not currently being considered for publication elsewhere, all authors have been personally and actively involved in substantive work leading to the report and will hold themselves jointly and individually responsible for its content, and all relevant ethical safeguards have been met in relation to patient or subject protection.
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What is already known on this subject: • Alcohol misuse is more common in regional and remote areas compared with urban areas in Australia. • The regional and urban differences in risky alcohol use and alcohol-related harm in adult populations are well documented. However, only a limited number of studies have focused on adolescents, and little empirical research has investigated why such differences exist.
alcohol use and harm among adults are relatively well documented, limited empirical research has focused on factors that account for urban/regional differences in alcohol use.4 The present paper investigates whether urban/regional differences can be explained by differences in parental disapproval of alcohol use. During adolescence, parents can play an important protective role in reducing alcohol-related risk and suppressing the development of harmful drinking habits in their children.8,9 With regard to alcohol use, parental influences remain important into young adulthood.10 In particular, parental attitudes towards alcohol use have been shown to be strongly associated with their offsprings’ alcohol consumption.9,11 Van Der Vorst et al. observed that more conservative parental norms and attitudes towards alcohol use were associated with lower adolescent alcohol consumption.11 Similarly, Chan et al. found that when parents have liberal attitudes towards adolescent alcohol use, their children were three times more likely to show strong growth in their alcohol use during the adolescent years.8 Given the higher prevalence of early initiation of alcohol use12 and risky drinking in regional and rural areas, it is possible that parents in regional areas are more permissive towards adolescent alcohol use, and this can account for urban/regional variations.13 The aims of the present study were to examine whether there were regional and urban differences in rates of adolescent recent alcohol use, and whether parental disapproval of adolescent alcohol use accounted for these regional/urban differences. Since previous studies suggested that the effect of parental influence might be different at different stages of adolescent development,8 the analyses were stratified by grades (7, 9 and 11).
Methods Sample The sample consisted of 10 273 adolescents (49.34% men) at Grades 7, 9 and 11 (n = 3653, 3650 and 2970;
What this study adds: • This study examined regional and urban differences in adolescent alcohol use, and investigated whether parental attitudes to adolescent alcohol use explained urban/ regional variation. • Adolescents in regional areas were more likely to engage in recent alcohol use, and this regionality effect was partially accounted for by parental attitudes to adolescent alcohol use.
mean age = 12.51, 14.46 and 16.42). Of the initial sample, 9.81% had missing data in the analysis variable, and 10 multiply imputed datasets were used to estimate the missing values.14 There was no significant difference between participants from regional and urban areas in terms of age and gender (P > 0.05), but family affluence and country of birth were significantly associated with residency in regional or urban areas (P < 0.05). These factors were fully adjusted in the regression analyses.
Procedure A Victorian Adolescent Health and Wellbeing Survey, known as ‘HowRU?’, was conducted in 2009. The data collection involved a two-stage sampling strategy. In the first stage, schools were randomly selected from a stratified sampling frame of all schools in Victoria, Australia. In the second stage, classes in Grades 7, 9 and 11 were selected randomly. A detailed description of the sampling procedure can be found elsewhere.15
Measures The measures were based on an adapted version of the Communities That Care Youth Survey, a widely used epidemiological assessment instrument with established reliability and validity in the Australian context.16 Key variables included past month alcohol use, which was measured using the item ‘In the past 30 days, have you ever had more than just a few sips of an alcoholic beverage? 0 “No”, and 1 “Yes” ’. Regionality was determined based on the Australian Standard Geographical Classification – Remoteness Area.17 Under this classification scheme, regions were classified as ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’ based on the distance by road to the nearest urban centre, and population size. Since there were few areas classified as remote in Victoria, regional and remote areas were combined into a single category © 2015 National Rural Health Alliance Inc.
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‘regional or remote’. Parental disapproval of alcohol use was derived from the mean of three items (How wrong do your parents feel it would be for you to drink X regularly at least once or twice a month?, where X = ‘beer or wine’, ‘spirits’, and ‘pre-mixed drinks such as Bacardi Breezers© or UDL’s©’ respectively (1 ‘not wrong at all’ to 4 ‘very wrong’ (α = 0.93)). Demographic variables included age, gender, whether the participant was born in Australia and family affluence. Family affluence was measured using the Health Behaviour in School-Aged Children family affluence scale, and responses were coded as low, medium and high affluence.18
Analysis Statistical analyses were performed with Stata version 13 (StataCorp LP, College Station, TX). Three sets of models were used to investigate the research questions.19 Three models were run for each grade level (7, 9 and 11). In Model 1, alcohol use was regressed on regionality and demographic variables. This allowed the assessment of the total effect of regionality on alcohol TABLE 1:
use. In Model 2, parental disapproval of alcohol use was regressed on regionality and the demographic variables. This allowed the assessment of the effect of regionality on the parental disapproval. In Model 3, alcohol use was regressed on both regionality and parental disapproval, and the demographic variables. This allowed the assessment of both the direct effect of regionality and its indirect effects through parental disapproval on alcohol use. The significance of the mediation effect was examined by bootstrapping the product of the relevant regression coefficients.19
Results Prior to regression analyses, bivariate associations between alcohol use, regionality and the demographic variables were examined. Table 1 shows the descriptive statistics for each variable. At the bivariate level, alcohol use was associated with regionality, family affluence, birthplace, age, grade, parental disapproval of alcohol use, P < 0.001, but not gender, P = 0.055. Results from regression analyses are shown in Table 2. Results from Model 1 indicated that the total
Descriptive statistics of analysis variables by alcohol use Past 30 days alcohol use
Regionality Major cities Regional and remote area Gender Male Female Birthplace Australia Overseas Family affluence Low Medium High Grade 7 9 11 Age Parental disapproval of alcohol use†
No
Yes
n (%)
n (%)
5171 (64.97%) 912 (54.91%)
2788 (35.03%) 749 (45.09%)
3113 (64.37%) 3172 (62.51%)
1723 (35.63%) 1902 (37.49%)
5276 (61.66%) 963 (75.18%)
3281 (38.34%) 318 (24.82%)
87.77***
101 (68.71%) 1840 (66.21%) 4264 (62.18%)
46 (31.29%) 939 (33.79%) 2594 (37.82%)
15.68***
2875 2228 1182 M 13.91 3.44
608 1300 1717 M 15.09 2.53
χ2
59.67***
3.68
1190.13*** (82.54%) (63.15%) (40.77%) (SD) (1.61) (0.80)
(17.46%) (36.85%) (59.23%) (SD) (1.52) (0.98)
t 35.66*** 49.43***
***P < 0.001. †The responses to parental disapproval of alcohol use ranged from 1 to 4, and a higher score reflected stronger disapproval of alcohol use. © 2015 National Rural Health Alliance Inc.
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TABLE 2:
Regression coefficients and the associated interval estimates from the three sets of models for the mediation analysis
Grade 7 Regionality (Ref: major cities) Regional or remote area Parental disapproval of alcohol use Grade 9 Regionality (Ref: major cities) Regional or remote area Parental disapproval of alcohol use Grade 11 Regionality (Ref: major cities) Regional or remote area Parental disapproval of alcohol use
Past 30 days alcohol use
Parental disapproval of alcohol use
Past 30 days alcohol use
OR
95% CI
b
95% CI
OR
95% CI
1.83***
(1.47–2.28)
−0.12**
(−0.19, −0.04)
1.74*** 0.40***
(1.38–2.20) (0.37–0.45)
1.44***
(1.20–1.72)
−0.15***
(−0.23, −0.07)
1.32** 0.42***
(1.09–1.60) (0.39–0.46)
1.37***
(1.11–1.70)
−0.19***
(−0.29, −0.09)
1.21 0.41***
(0.96–1.53) (0.38–0.45)
**P < 0.01, ***P < 0.001. All these estimates were adjusted for age, gender, birthplace and family affluence.
effect of regionality on recent alcohol use was significant for all grade levels (P < 0.001). Results from Model 2 indicated that regionality was significantly associated with parental disapproval of alcohol use for all grade levels (P < 0.01). Results from Model 3 indicated that parental disapproval of alcohol use was significantly associated with recent alcohol use for all grade levels (P < 0.001). Regionality remained significant for Grades 7 and 9 (P < 0.01), but became non-significant for Grade 11 (P = 0.101). There were significant mediation effects evident in the bootstrapping procedure. The bootstrapped 95% CIs for the mediation effects were (0.04–0.18) for Grade 7, (0.04–0.19) for Grade 9 and (0.07–0.27) for Grade 11 (all P < 0.05). Results from the three sets of models indicated that adolescents in major cities were less likely to use alcohol in the past 30 days, and the regionality effect was partially mediated by a higher level of parental disapproval in urban area. A comparison of the direct effect (from Model 3) and total effect (from Model 1) for regionality indicated that 8.37%, 23.30% and 39.22% of the effect for regionality were mediated through parental disapproval of alcohol use for Grade 7, 9 and 11 participants respectively. The results of a supplementary analysis with only complete cases were similar to those from the imputed data, indicating that the results of the analysis were not greatly affected by missing data.
Discussion Adolescents in regional areas were more likely to engage in recent alcohol use, and this effect was partially explained by parental disapproval of adolescent alcohol use. These results indicated that parental disapproval of
alcohol use contributes to the variation in alcohol use across regional and urban areas. While the effects of parental disapproval were similar for all grade levels (Model 3), parental disapproval explained a larger proportion of variation in alcohol use for older than younger adolescents. The findings have implications for prevention and early intervention programs for regional communities. First, the results extend earlier research showing greater alcohol-related risks for adolescents in regional communities by confirming that adolescent alcohol use might be more prevalent in regional than in urban areas. The majority of past research on regional and rural alcohol use has focused on adults. Our results support previous findings12 in showing that the divergence in alcohol use between regional and urban areas begins early and before mid-adolescence (Grade 7, mean age = 12.5). These findings support the importance of increasing efforts in regional areas to discourage adolescent alcohol use and to increase parent education. Regional centres can benefit from improved resources, training and provision of evidence-based prevention programs.13,20 Community programs that deliver coordinated, comprehensive and consistent messages have been shown to be effective.21 Youth-focused community coalitions that use evidence-based approaches to more broadly address a range of identified local community risk/protective factors can prevent adolescent substance use. These community-based approaches require local investment, shared goals and the adoption of evidencebased prevention approaches to address local health priorities. Second, our findings point to the utility of strengthening adolescent and parent-oriented prevention pro© 2015 National Rural Health Alliance Inc.
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grams in regional communities. Smith et al. highlight the need for more integrated approaches that target multiple risk factors, cautioning against simply applying ‘area-based’ explanations to Australian rural health problems.22 The disparity in regional and urban areas can be exacerbated by parental attitudes that are more tolerant of heavier adult drinking and a more prodrinking culture. Community-based prevention strategies that aim to form coalitions of local organisations and services to increase parental awareness of national alcohol guidelines and their role in reducing the supply of alcohol to adolescents can be important strategies to reduce adolescent drinking in regional areas.20 The study is not without limitations. The crosssectional survey design precludes conclusions about causality. Consistent with most epidemiological studies, the data were based on adolescent self-report. Information on parental alcohol use would have assisted in interpreting differences in rural and urban attitudes towards adolescent drinking. Only a dichotomised response of 30-day alcohol use (yes/no) was used in the present study and the level of consumption was not examined. Nonetheless, the latest NHMRC guideline3 recommends that adolescents under 18 should remain abstinent from alcohol for as long as possible. The present study contributed to the understanding of factors that explained the difference in rates of recent alcohol use for adolescents in regional compared with urban areas. While parental disapproval was a very strong and consistent predictor of alcohol use across grades, it only explained a small to medium proportion of the variation between regional and urban areas for adolescents. In particular, only 8% of the variation was accounted for in Grade 7, compared with 39% in Grade 11. A range of unmeasured factors such as community supply of alcohol and adult alcohol use behaviours might have also contributed to the higher prevalence of adolescent alcohol use in regional areas. Future research could investigate the mediating role of these factors in explaining the observed urban and regional differences. Despite these limitations, this study has several strengths, including a large sample size and a statistical design that allowed examination of parenting factors, with controls for family affluence and cultural background.
Conclusion There was a large difference in adolescent alcohol use between regional and urban areas that was partially accounted for by parental disapproval of alcohol use. Efforts should be increased to reduce adolescent alcohol use in regional communities. Building parent awareness about the risks of alcohol use and managing alcoholrelated rules may be an important prevention component, particularly in regional areas. © 2015 National Rural Health Alliance Inc.
Acknowledgements This study was supported through internal funds and via the Australian Research Council Project DP130102015 to A.B.K., J.P.C and R. McD. Y. (second, third and fifth author). J.P.C. (third author) is supported by a National Health and Medical Research Council (NH&MRC) of Australia Career Development Fellowship (1031909). These funding bodies had no role in the design, analysis or interpretation of the data. The authors thank Ms. Janni Leung for her expertise in rural health. The data on which this study is based were collected as part of the HOWRU Survey, a collaboration between the Centre for Adolescent Health and the Department of Education, Victoria, Australia.
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