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CHAPTER 2

LITERATURE REVIEW

This chapter consists of a review of the literature related to alcohol drinking.


The discussion begins with situation of alcohol drinking in Vietnam, impacts of
alcohol drinking in Vietnam, and effects of alcohol consumption. This is followed by
a presentation of the Theory of Triadic Influence (TTI). The related literature on
alcohol drinking delineates some of the factors related to alcohol drinking behavior
among adolescents.

Situation of alcohol drinking in Vietnam


Vietnam is a developing country with a population of over 85 million in
2009. According to the 2009 Vietnam Population and Housing Census, there was
approximate 45% of the population of Vietnam was under 25 years old (Central
Population, 2010). During the previous decades, Vietnam was one of the poorest
countries in Asia. However, since 1986, Vietnam has undergone multiple economic
and reforms with the establishment of a more liberalized market system. Since that
time, the increasing development and industrialization in Vietnam, the socio-economy
had had subsequently increased. As a consequence, a shift of traditional lifestyle to a
more westernized one is taking place (HSPI, 2006). These changes have resulted in a
reduction in the poverty rate from 60% to 20% over the past 15 years (World Bank,
2007). The economy and society in Vietnam are changing rapidly because
international joint ventures lead to the decreasing of social, economic and political
isolation. Foreign media and internet access are available and there are rapid increases
in tourism. Therefore, Vietnamese adolescents today have greater educational
opportunity and increasing access to information, goods and services than their
parents (Haub & Huong, 2003 cited in Kaljee et al., 2005).
Moreover, Kaljee et al. (2005) also indicated that joint business ventures for
beer and other alcoholic beverages, as well as the increasing availability and visibility
of both national and imported brands, were most certainly affecting drinking patterns
among the Vietnamese, particularly for youth. National and international beer
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companies hire young women as “representatives” to promote a particular product


and encourage the purchase of their beverages in restaurants and cafes. When beer is
ordered, a crate of beer is brought to the table, and as each bottle is emptied a new
bottle is opened by the promoter (Kaljee et al., 2009). Drinking is a common
phenomenon in Vietnam where alcohol is not only used to celebrate events, as part of
socialization, to facilitate business, and sometimes to reduce sadness, but also often
used to have fun and enhance a good time. Moreover, large numbers of Vietnamese
say “A man without alcohol is like a flag without wind”. Toasting and drinking
“games” - “drink 100%”, are very common practices in Vietnam (Tho et al., 2007).
Therefore, the culture and social context for alcohol use is accepted, perhaps
unintentionally facilitating alcohol use among adolescents and young people (Kaljee
et al., 2009). Drinking is a social activity in Vietnam, for young men, they often drink
together in cafes and small beer restaurants. Young men drink as a way to exhibit
their transition from boyhood to manhood, whereas young women more often drink
either in mixed gender groups or alone with a boyfriend. The behavior of these young
women in drinking is a rejection of the “traditional” social norms, which views
alcohol consumption as primarily a part of the male domain (Kaljee et al., 2005).
Consequently, the tendency of using alcohol in daily life, during festive
occasions and business relationships, etc. is increasing (HSPI, 2006). Vietnamese
adolescents and youths are consuming more alcohol and at younger ages than in the
past (Vietbao, 2006). There was 80% of male and 37% of female adolescents and
young adults had consumed alcohol in Vietnam (MOH, 2010). In Khanh Hoa
province, 29.2% of adolescents reported ever drinking alcohol (Kaljee et al., 2005).
There was an association between alcohol use and lifestyle factors among Vietnamese
youths. In the establishments in Vietnam, such as “karaoke and hugs, beer and hugs”,
large quantities of alcohol were consumed (Kaljee, 2009). More drinkers (41%) used
the internet than non-drinkers (18.8%) (p = 0.034). Concerning youth and recreation,
a significantly greater proportion of drinkers reported drinking as compared to non-
drinkers at the places for example, 75.8% of drinkers compared to 44.4% of non-
drinkers went to coffee shops (p < 0.001), 57.2% of drinkers compared to 44.9% of
non-drinkers went to restaurants (p = 001), 30.1% of drinkers compared to 14.2% of
non-drinkers went to karaoke (p < 0.001), 21.8% of drinkers compared to 9.5% of
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non-drinkers went to billiards-halls (p < 0.001) and 28.5% of drinkers compared to


3.7% of non-drinkers went to drinking houses (p < 0.001) (Tho et al., 2007).
According to Health Strategy and Policy Institute of Vietnam (2006), the use
of alcohol in Vietnam is increasing due to the combination of many factors: customs,
cultural standard, improved living standard, need of social communication, the
increasing market of alcohol production and supply, expanding alcohol advertising
and marketing activities, etc. (HSPI, 2006). The production of alcohol beverages has
increased quickly in Vietnam. Over the years, the production of beer increased 30%
per year from 1990 to1996, and then continue increased from10% to15% every year.
In addition, the production of wine was estimated at approximately 120 million liters
per year not including tens of millions of liters of wines imported and smuggled
alcohol products (Vietbao, 2006). Besides, other unrecorded alcohol products such as
homemade wines (informally produced), illegally produced in Vietnam are also the
big problem because 95.7% of Vietnamese wine drinkers consume homemade wines
(Cuong & Hanh, 2009). In Vietnam, people of any age can purchase and consume
alcohol beverages almost everywhere, from sidewalks, cafe shops, restaurants, or
luxury hotels (Vietbao, 2006).

Impacts of alcohol drinking in Vietnam


Alcohol overuse results in serious consequences for the community health
and society in Vietnam. It was shown that approximately 4.4% of the Vietnamese
suffered from diseases and injuries related to alcohol (MOH, 2006). At the Hospital of
Mental Health, Vietnam, the proportion of psychiatric treatment accounted for 5-6%
alcoholic psychiatric patients. This percentage had increased in five years, from 4.4%
in 2001 to 7.03% in 2005. Alcohol poisoning has also actually become a risk affecting
the lives and health in Vietnamese drinkers. The case fatality rate from alcohol
poisoning in Vietnam was approximately 21.4%. There were 9 drinkers in the North
and 15 drinkers in the South of Vietnam who died due to alcohol poisoning from 2000
to 2008. In Ho Chi Minh City, there were 10 drinkers died between September 29 and
October 20, 2008 from the poisoning of alcohol (Vietnam Food Administration,
2009). In addition, the prevalence of the road traffic deaths involving alcohol was
34% in Vietnam (WHO, 2011 b). Alcohol consumption among adolescents and
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youths in some places such as karaoke & hugs, beer & hugs is the immediate access
to commercial sex workers and unsafe sexual behavior. Therefore, the consumption of
alcohol has been correlated with a higher prevalence for sexually transmitted diseases
including HIV/ AIDS as well as unwanted pregnancy in adolescents and youths in
Vietnam (Kaljee et al., 2005; Tho et al., 2007). Viet Nam has one of the world’s
highest abortion rates with an estimated rate of 83.3 per 1,000 women receiving
abortions including 300,000 abortions performed annually for women below 19 years
old. However, many abortions are performed in private clinics and are not reported to
the local government health department (Alan Guttmacher Institute, 1999). Moreover,
the harmful use of alcohol also results in theft, criminal damage, robbery, or selling
illegal drugs by Vietnamese adolescents (MOH, 2009). The prevalence of juvenile
crime is increasing in recent years. According to Ministry of Security Vietnam, there
were 15,589 juvenile crimes in Vietnam by the year 2007 (Nguyen, 2008).
Diseases and injuries attributed to alcohol kill millions and harm tens of
millions of people each year worldwide. The health and well-being of many young
people today are seriously threatened by the use of alcohol (WHO, 2004 b). But the
negative impacts of alcohol consumption can be reduced through prevention and
treatment policies that are shown to work - if governments will adopt and enforce
them (WHO, 2011 c). However, the effects of the drinking reaction policies in
Vietnam are still insignificant because in general these laws have not been
implemented (Alcohol Reports, 2009; HSPI, 2006; WHO, 2004 c, 2011 c).

Effects of alcohol consumption


Alcohol use is related to wide range of physical, mental and social harms.
Most health professionals agree that alcohol affects practically every organ in the
human body (WHO, 2004 b). From a public health perspective, the global burden
related to alcohol consumption, both in terms of morbidity and mortality, is
considerable in most parts of the world. Alcohol consumption has health and social
consequences via intoxication, alcohol dependence, and other biochemical effects. It
may create chronic diseases after many years of heavy use. Moreover, alcohol abuse
could contribute to traumatic outcomes that kill or disable drinkers at a relatively
young age, resulting in the loss of many years of life due to death or disability. Health
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outcomes relevant to alcohol consumption and pattern of drinking are evidently


increasing. Overall there is a causal relationship between alcohol consumption and
more than 60 types of disease and injury. Alcohol is estimated to cause about 20–30%
of oesophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures,
and motor vehicle accidents worldwide (The World Health Report, 2002).
Biological effects of alcohol consumption
The impact of alcohol consumption on disease and injury is associated with
two separate but related dimensions of drinking by individuals: the volume of alcohol
consumed and the pattern of drinking (WHO, 2004 b).
Liver cirrhosis and pancreatitis (both acute and chronic) can also be caused
by alcohol consumption. Higher levels of alcohol consumption create an exponential
risk increase (Pace et al., 2009). Additionally, alcohol consumption has been
identified as carcinogenic for the following cancer categories: cancers of the
colorectal, female breast, larynx, liver, oesophagus, oral cavity and pharynx. This
identification reflects that the higher the consumption of alcohol, the greater the risk
for these cancers (Baan et al., 2007). The relationship between alcohol consumption
and cardiovascular diseases is complex. Light to moderate drinking can have a
beneficial impact on morbidity and mortality for ischaemic heart disease and
ischaemic stroke. However, the beneficial cardioprotective effect of drinking
disappears with heavy drinking occasions. Roerecke and Rehm (2010) have shown
that light to moderate drinkers experienced no protective effect if they reported at
least one heavy drinking occasion per month. Moreover, alcohol consumption has
detrimental effects on hypertension, cardiac dysrhythmias and haemorrhagic stroke,
regardless of the drinking pattern (Rehm et al., 2010). There was a dual relationship
between alcohol consumption and diabetes mellitus (Baliunas, Rehm, Irving, &
Shuper, 2010).
In addition to the disease, new evidence points to a causal link between
alcohol and infectious diseases. Namely, alcohol consumption weakens the immune
system, thus enabling infections by pathogens, which cause pneumonia and
tuberculosis. This effect is markedly more pronounced with heavy drinking and there
may be a threshold effect (Lönnroth, Williams, Stadlin, Jaramillo, & Dye, 2008). A
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strong association exists between alcohol consumption and HIV infection and
sexually transmitted diseases (Baliunas et al., 2010).
Psychological effects of alcohol consumption
Besides the numerous chronic and acute health effects, alcohol consumption
is also associated with widespread psychological consequences. Alcohol is implicated
in a variety of mental disorders, which are not alcohol-specific. While the causality of
the relation is hard to define, sufficient evidence now exists to assume alcohol’s
causal role in depression, a common mental disorder (WHO, 2004 b). Samokhvalov,
Irving, Mohapatra, and Rehm (2010) also indicated that neuropsychiatric disorders are
the most important disorders caused by alcohol consumption. Epilepsy is another
disease causally impacted by alcohol, over and above withdrawal-induced seizures
and many other neuropsychiatric disorders are associated with alcohol.
In the general population, alcohol dependence and major depression co-
occur over proportionally, on both a 12-month and a lifetime basis (Kessler et al.,
1996; Kessler et al., 1997; Lynskey, 1998). Among alcohol consumers in the general
population, higher volume of consumption is associated with more symptoms of
depression (Graham & Schmidt, 1999). Among patients in treatment for alcohol abuse
and dependence, the prevalence of major depression is higher than in the general
population (Lynskey, 1998). Higher prevalence of alcohol use disorders has also been
documented for patients in treatment for depression (Blixen, McDougall, & Suen,
1997). This suggests that alcohol use disorders are linked to depressive symptoms,
and that alcohol dependence and depressive disorders co-occur to a larger degree than
expected by chance. However, it is not clear in any individual case whether
depression leads to alcohol problems, or whether the alcohol consumption or alcohol
problems cause depression, or both could be attributed to a third cause (Vaillant,
1993).
There is also a direct link between alcohol abuse and other psychiatric
disorders, for instance, the drug abuse and dependence, other addictive disorders,
anxiety disorders, insomnia, memory problems, and suicide attempts. In addition,
overuse of alcohol causes lack of coordination, fatigue and weakness. It can
exaggerate antisocial behaviors such as irritability, anger and aggression (Larson,
1999).
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Social effects of alcohol consumption


Alcohol consumption is also related to social harms. It causes harm far
beyond the physical and psychological health of the drinkers. It also causes harm to
well-being and health of others. Diseases and injuries, for instance, have social
implications, including medical costs, which are borne by governments, negative
effects on productivity, and financial and psychological burdens on families. Social
harm from drinking can be classified in terms of how they affect important roles and
responsibilities of everyday life: work, family, friendship and public character.
Intoxication interferes to a greater or lesser extent with most productive labour. A
drinker’s own productivity is reduced, and there may be adverse social consequences
for the drinker, including loss of his/her job. The productivity of others around the
drinker may be diminished if they have to take time out of their work to cover for the
drinker’s mistakes, absences or lateness. Similarly, the ability as a parent or guardian
to care for children is adversely affected by intoxication. There may be serious
adverse immediate and long-term effects for the children such as neglected or abused
by the drinker. There also may be serious consequences for the drinker from family
members, social services or public safety authorities in response to neglect or abuse
by the drinker (WHO, 2011b). Drinking and intoxication can also adversely affect
intimate and family relations, and friendships. The adverse effects are often most
clearly visible in small and isolated communities (Room, Jernigan, Carlini-Cotrim,
Mäkelä, & Marshall, 2002).
Besides the adverse social impact on family members, relatives, friends and
co-workers, alcohol drinking can also impact on strangers (Laslett et al., 2010), who
can be victims of road traffic accidents caused by a drunk driver or be assaulted by an
intoxicated person (Room et al., 2002). Intoxicated people commit many crimes
where the victims are unknown to the perpetrators, including homicide, robbery,
sexual assault and property crimes. Verbal threats, noise and nuisance from
intoxicated people can also affect the wellbeing of others. Again, these offences often
also impact the drinker if she or he is arrested and punished (WHO, 2011 b).
Alcohol can also do harm at the level of society, beyond small groups such
as families. For instance, heavy lunchtime drinking at factories may affect the quality
of work and the economic survival of the factories without it actually affecting any
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particular person. This, in turn, can affect the economic viability of a community that
depends on factory jobs. In this way, widespread heavy drinking can adversely affect
whole societies (Room et al., 2002). The economic consequences of expenditures on
alcohol are significant especially in high poverty areas. Besides money spent on
alcohol, a heavy drinker also suffers other adverse economic effects. These include
lowered wages, lost employment opportunities, increased medical expenses for illness
and accidents, legal cost of drink-related offences, and decreased eligibility of loans.
It is important to note that the alcohol-attributable costs go far beyond the health
sector costs; it is very costly for society as a whole, including the costs to
governments and citizens and, to a certain extent, to drinkers themselves (WHO, 2004
b).
Developmental effects of alcohol consumption
Alcohol is a physical and behavioral teratogen. At the earliest ages, young
people are vulnerable to the effects of the drinking of others. Children exposed to
alcohol during pregnancy are at risk for fetal alcohol syndrome, alcohol-related birth
defects, and alcohol-related neuro-developmental disorder. Alcohol consumption by
an expectant mother may cause fetal alcohol syndrome and pre-term birth
complication conditions, which are detrimental to the health and development of
neonates (WHO, 2011 b).
Whatever it is that leads children to begin drinking, once they start facing a
number of potential health risks. Although severe health problems associated with
harmful alcohol use are not as common in children as they are in adults, studies show
that young people who drink heavily may put themselves at risk for a range of
potential health problems (Jernigan, 2001). Heavy alcohol use at a young age is
predictive of a range of psychological and physical problems. Protracted and
continuous abuse of alcohol may be predictive of more severe health problems in
general for boys and girls (Aarons et al., 1999).
Scientists currently examine how alcohol affects the developing brain, but it
is a difficult task. Subtle changes in the brain may be difficult to detect but still have a
significant impact on long-term thinking and memory skills. Add to this fact,
adolescent brains are still maturing, and the study of alcohol’s effects becomes even
more complex. It is simply not known how alcohol will affect the long-term memory
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and learning skills of people who begin drinking heavily at adolescent age (White,
Jamieson-Drake, & Swartzwelder, 2002).
Alcohol use disorders during adolescence were associated with more health
problems: higher liver enzymes indicating some degree of liver damage and more
physical examination abnormalities (Clark, Lynch, Donovan, & Block, 2001).
Besides, young drinkers who are overweight or obese showed elevated liver enzymes
even with only moderate levels of drinking (Strauss, Barlow, & Dietz, 2000).
Regarding the growth and endocrine effects of alcohol consumption in
adolescents, Mauras, Rogol, Haymond, and Veldhuis showed that in both males and
females, puberty is a period associated with marked hormonal changes, including
increase in the sex hormones, estrogen and testosterone; these hormones, in turn,
increase production of other hormones and growth factors, which are vital for normal
organ development. Drinking alcohol during this period of rapid growth and
development (i.e., prior to or during puberty) may upset the critical hormonal balance
necessary for normal development of organs, muscles, and bones. Dees, Srivastava,
and Hiney (2001) also showed that consuming alcohol during puberty adversely
affects the maturation of the reproductive system. Alcohol impairs ovarian function
not only by interfering with hormonal communication between the brain, pituitary
gland, and ovaries but also by directly altering the function of regulatory systems
within the ovaries themselves.
There is a strong relationship between early onset of drinking and later
development of alcohol use disorders (Grant, Stinson, & Harford, 2001). Adolescents
who begin drinking at a younger age also tend to have lower self-esteem, be less
resistant to peer pressure and display anti-social features (Flory, Lynam, Milich,
Leukefeld, & Clayton, 2004).
Drinking by parents may also harm family life, leading to a variety of
deleterious effects on young people. Problems for the young people in such homes
may include instability or collapse of marriages and family structures, increased risk
of physical or sexual abuse, neglect, and strain on family finances. Such family
problems may in turn put young people at greater risk of developing anti-social
behaviors, emotional problems and problems in the school environment (Velleman,
1993).
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The Theory of Triadic Influence (TTI)


Over the past decades, there have been several theories of health behavior.
Each theory has its own specificity and focus. Some theories of health behavior focus
on proximal cognitive predictors of behavior, while others focus on expectancy-value
formulations or social support and bonding processes. Some theories focus on social
learning processes, while others point towards personality and intrapersonal
processes. Flay and Petraitis proposed a new comprehensive theory that integrates
constructs from all previous theories: the Theory of Triadic Influence (TTI) (Flay &
Petraitis, 1994). This theory was originally formulated in the context of adolescent
substance use such as tobacco, alcohol, or an illicit substance (Flay & Petraitis, 1993).
The TTI includes three major streams of influence to explain the behavior of youths:
interpersonal (social) influences, attitudinal (social-cultural) influences, and
intrapersonal (personal) influences. Each of these streams includes significant
variables that range from the very ultimate to the distal and proximal.
In general, the TTI contends that attitudinal, social, and intrapersonal
influences independently and interactively affect decisions to act or not act in a
certain way, for example to use or refuse a substance. The theory is intended to
account for factors that have direct effects as well as indirect effects on behavior. In
addition to the direct influences through the streams, there are important interstream
effects and influences that flow between levels. The TTI is also intended to account
for both new behaviors and regular behavior. Experiences with related behaviors and
early experiences with a new behavior lead to feedback loops through all three
streams adding to the prior influences of these streams (Flay & Petraitis, 1994). Some
variables (like intentions) have direct effects on behavior and are causally proximal or
immediate; some variables (like motivation to comply with or please others) have
effects that are mediated through other variables (like social normative beliefs) and
are more causally distal or predisposing; other variables such as access to information
or knowledge and availability of behavior are mediated by even more variables and
are even more causally distal; and yet other variables (like ethnic culture,
neighborhood poverty, or personality) represent the underlying or ultimate causes of
behavior (Flay, 1999; Flay & Petraitis, 1994; Flay, Snyder, & Petraitis, 2009).
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Attitudinal influences on health-related behaviors (HRBs)


According to the TTI, the broad socio-cultural or macro environmental
factors contribute indirectly to health-related beliefs and attitudes, by contributing
more directly to health-related knowledge, values, expectations, and evaluations. This
stream provides a world of information about health. Information provided by
sociocultural environment, however, is not likely to affect HRBs directly in a
stimulus-response manner and interventions, which rely primarily on disseminating
health-related information that is unlikely to have sizable effects on HRBs. Rather, the
TTI asserts that such information merely contributes to one’s base of knowledge
about the causes of health threats and ways to avoid these threats. In turn, knowledge
about health threats can contribute to one’s expectations regarding the possible
consequences of HRBs. In addition to shaping health-related knowledge, the broad
sociocultural environment is also hypothesized to shape health-related values. The
TTI recognizes that government, school, news media, entertainers, advertisers, and
other people with whom individuals have little personal contact can transmit many
cultural values. Over time, widespread sociocultural values are thought to shape
health-related values, such that personal health will take on more salience when
government, school, the media, and society in general emphasize health. In turn,
health-related values contribute to HRBs; however, they cannot affect HRBs directly,
and that their primary effects will be on how people evaluate the expected
consequences of various HRBs (Flay & Petraitis, 1994).
The TTI also contends that health-related beliefs and personal values
converge to shape attitudes toward HRBs. The attitudes toward most HRBs are
shaped by expectations regarding the health, financial, and social consequences of a
given health-related behavior (HRB) (i.e., outcome expectancies); and evaluations of
those consequences. Moreover, the theory assumes that expectations are shaped by
exposure to health-related information from the broad sociocultural environment, and
evaluations are shaped by health-related values, which are transmitted from the
sociocultural environment. These forces combine to shape health-related attitudes,
which, in turn, contribute to decisions to engage in a health-promoting behavior or a
health-compromising behavior (Flay & Petraitis, 1994).
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Social influences on health-related behaviors


Empirical evidence suggests that social influences play a major role in
HRBs in general and substance use in particular. The second stream of the TTI
originates in an individual’s more immediate social setting or microenvironment
including neighborhoods/ family organizations, parenting styles, and parental values.
It consists of factors that are thought to affect HRBs by shaping perceived social
pressures to adopt or maintain a given HRB. The theoretical origins of the social
stream lie in the assumption that one’s own HRBs can be shaped by observing and
imitating the attitudes and behaviors of other people to whom one is most closely
bonded (Flay & Petraitis, 1994).
The TTI assumes that conditions in an individual’s immediate social
surroundings contribute to HRBs in two ways. First, social psychologists have long
known that one of the best predictors of affiliation and friendship patterns is
proximity, such that we bond with those people with whom we spend the most time.
Thus, the TTI assumes that immediate social settings or contexts will directly affect to
whom an individual becomes most closely bonded and will indirectly affect with
whom an individual is motivated to comply. Second, as sociologists would point out,
HRBs are not evenly distributed within a culture, and there are pockets where some
health-compromising behaviors are widespread and others where they are less
common. Recognizing this, the TTI assumes that social settings or microenvironments
can contribute to an individual‘s HRBs by affecting the health-related attitudes,
values, and behaviors of other people in the same environment such as parents, other
adults, and peers. In turn, these factors are thought to affect one’s perceptions of
norms concerning a given behavior. The TTI also assumes that sets of perceived
norms combine with the individual’s motivation to comply and together directly
produce to affect social normative beliefs (e.g., perceived approval of parents and
peers), and to shape decisions to adopt a particular HRB indirectly (Flay & Petraitis,
1994).
Intrapersonal influences on health-related behaviors
Although the TTI asserts that social and attitudinal influences affect health-
related decisions, it recognizes that two people under similar social conditions and
with similar attitudes toward HRBs might not make identical decisions regarding
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HRBs. Instead, the theory recognizes that inherited traits and personality dispositions
might also contribute to health-related decisions and behaviors. The personality can
be characterized along five basic dimensions, sometimes called “The Big Five”.
These are (1) behavioral control (e.g., behavioral constraint, impulsivity, task
persistence, hyperactivity, aggressiveness, and motivation to achieve); (2) emotional
control (e.g., psychological adjustment, emotional stability, neuroticism, and
emotional distress); (3) extraversion/introversion (e.g., social activity, social
adaptability, and assertiveness); (4) sociability (e.g., likability, friendliness,
compliance, and conformity); and (5) intellect or general intelligence (Flay &
Petraitis, 1994).
The dimensions of behavioral control and emotional control are thought to
contribute to HRBs by shaping health-related self determination. The TTI takes the
position that one’s general ability to control his or her behaviors and emotions might
affect one’s sense of self or self-concept (e.g., ego integration, self-esteem/
derogation, and self-image) such that people who can control their actions and moods
are likely to develop stronger self-esteems and more coherent self-concepts. In turn,
they are hypothesized to place greater value on self-determination when it comes to
HRBs. As a general rule, the TTI assumes that people with stronger self-
determination (i.e., will) should be more interested in planning, regulating, and
restraining their HRBs. By contrast, those who hold unfavorable or incoherent images
of themselves are assumed to be more prone to take risks, act impulsively, and not
care as much about the possible consequences of their HRBs. Similarly, the third and
fourth dimensions are thought to contribute to HRBs by shaping one’s health-related
skills. Introversion and weak sociability are two traits thought to affect adversely
one’s general social competence (e.g., academic skills, social interaction skills, and
general social skills). Poor social competence, in turn, is likely to affect a person’s
perceptions of his or her skills at performing HRBs, such that people who are
introverted and have trouble getting along in social situations might come to doubt
their ability to successfully complete a health-promoting behavior. The health-related
self-efficacy is shaped by self- determination or will to control behaviors in general,
and perceptions of personal skills in controlling HRBs in particular. People who have
the will to control their behaviors, and believe they have the skills to perform a given
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HRB should have stronger health-related self-efficacy and should be more likely to
decide to adopt health-promoting behaviors (Flay & Petraitis, 1994).
Two features of interstream paths are worth special attention. First, the
effects of interstream paths can be either additive or interactive. Additive paths are
those where a variable in one stream contributes to a variable in another stream.
Interactive paths, by contrast, are those where a variable in one stream modifies the
effect of a variable in another stream. Second, interstream pathways demonstrate the
overpowering importance of the most distal or “ultimate” causes of HRBs. Because
the effects of the streams flow both within and between streams, they contribute to
HRBs in innumerable ways (Flay & Petraitis, 1994).
In summary, The TTI is one of the most comprehensive and integrative
theories of health behavior to date and is actually relevant for behaviors of youths.
The TTI includes three primary streams of influence on health-related behaviors.
These streams independently and simultaneously influence decisions to act or not to
act in behaviors. All influences do not flow neatly down one stream or another;
therefore, the effects might also contribute to others. Moreover, the influences on
behavior comprise a dynamic process and any experiences with health-related
behavior feedback and change the original causes of that behavior. This theory also
involves both direct as well as indirect factors affecting HRBs and points to different
streams and levels of influences from the ultimate to distal and proximal level (Flay,
1999; Flay & Petraitis 1993; Flay & Petraitis, 1994; Flay et al., 2009).
Therefore, the TTI provides a broader framework for understanding the
alcohol drinking behaviors among adolescents. This study is not attempt to test TTI
framework, rather this framework will be used to guide the factors explaining the
alcohol drinking behaviors among Vietnamese adolescents.

Factors related to alcohol drinking behavior in adolescents


Intrapersonal influences
Age Alcohol use frequently onsets and shows rapid growth during the
adolescent years (Capaldi et al., 2009). Age is a significant factor related to alcohol
use. The number of students who drink increases with grade levels and decrease with
initial drinking age (Fox, McManus, & Arnold, 2010; Hong et al., 2011; Kaljee et al.,
27 

2005; McCoy et al., 2010; Scholte et al., 2008). According to data from the 2010
Monitoring the Future study, an annual survey of U.S. adolescents, the results showed
that frequency of drinking and drinking problems increased with grade levels and
decreased with initial drinking age. 29.3% of 8th graders, 52.1% of 10th graders, and
65.2% of 12th graders had consumed alcohol. 11.5% of 8th graders, 29.9% of 10th
graders, and 44.0% of 12th graders had engaged in heavy episodic drinking (Johnston,
O’Malley, Bachman, & Schulenberg, 2010). Piastrelli et al. (2011) also indicated
alcohol consumption increased with age, significantly more 12th graders than 11th
graders had consumed alcohol (71.4% versus 54.3%; p = 0.002). In another study,
Begue and Roche (2009) revealed that age was a significant factor associated with
alcohol drinking behavior among adolescents. The researchers observed on 1,295
participants aged 14-19 years old in Grenoble City of France. Bivariate analyses
indicated that 13% among 14-15 years old had been drunk in the last year, 35%
among 16 -17 years old and 52% among 18-19 years old (χ2 = 133.28, p < 0.000).
This result is accordant with the results in several previous studies, such as study of
Fox et al. (2010), Hong et al. (2011), McCoy et al. (2010), Scholte et al. (2008).
In Khanh Hoa Province Vietnam, Kaljee et al. (2005) revealed that
adolescents who reported using alcohol were significantly older than those who
reported no alcohol use (t = -3.6, df = 478, p < 0.00). Researchers also suggested that
youths consumed more alcohol and at younger ages than in the past. In another study,
Tho et al. (2007) indicated that there was a strong association between age group and
alcohol use, alcohol consumption increased with older age group (p < 0.001).
Overall, several findings indicated that age was a significant factor related to
alcohol use among adolescents. Adolescent alcohol consumption increased with age.
This study would like to examine whether older adolescents are more likely to drink
than younger ones in Vietnam.
Gender Gender is also a significant factor associated with drinking alcohol
among adolescents. Many studies have consistently shown that male youths are more
likely than female youths in drinking alcohol (Begue & Roche, 2009; Brook &
Tepper, 2002; Htay et al., 2010; Kaljee et al., 2009; Simons et al., 2010). A study in
Thailand, Assanangkornchai, Pattanasattayawong, Samangsri, and Mukthong (2007)
examined 3-year trends and attitude towards substance use (alcohol, tobacco, and
28 

other drugs) (2002-2004) among adolescents in Southern Thailand. The results


revealed that male adolescents were more likely to use substances than female
adolescents (OR = 6.57, 95% CI = 4.86-8.89). Begue and Roche (2009) surveyed in
Grenoble City of France showed that there was a different significance about alcohol
drinking between males and females, boys engage in alcohol consumption higher than
girls (38% of boys and 21% of girls) (χ2 = 40.52, p < 0.000). In another study, a total
of 410 Latino adolescents aged 14-19 years were recruited from community venues
from years 2001 to 2004 and followed up for 2 years. The results indicated that 60%
of boys reported drinking alcohol at least weekly in at least one 6-month interval as
compared with 45% of girls (p = .02), and 42% reported getting drunk at least weekly
as compared with 24% of girls (p < .01) (McCoy et al., 2010).
Htay et al. (2010) conducted a cross-sectional study of the risk behaviors
inherent in tobacco smoking, alcohol consumption and premarital sex, among 400
medical students (186 males) from a medical university, Yangon, and 410 community
youths (244 males) from selected townships in Myanmar, found that, there was a
significant difference in the prevalence of all risk behaviors between male and female
respondents. Such risk behaviors were more dominant among males, while being very
low among females. 34.5% of medical students (58.5% of males and 13.8% of
females) had consumed alcohol. Moreover, the relations between attitude towards
alcoholic drinks and alcohol consumption were stronger for boys than for girls (Roek
et al., 2010).
According to WHO (2011 a), data from the different countries (in countries
of WHO regions around the world) range from 2003 to 2010 give an overview of the
national data concerning current drinking among young people aged 13-15 years
showed a difference in alcohol consumption between boys and girls. The national data
from Benin (WHO African Region) indicated that 18.2% of male students and 12.5%
of female students who drank at least one drink containing alcohol on one or more of
the past 30 days. The national data from Guyana (WHO Region of the Americas)
showed 46.9% male and 25.9% female adolescents consumed alcohol. In Lebanon
(WHO Eastern Mediterranean Region), there were 28.5% of males and 12.3% of
females drank alcohol. The Former Yugoslav Republic of Macedonia (WHO
European Region) reported the prevalence of alcohol drinking among adolescents was
29 

40.8% for males and 30.6% for females. In WHO South-East Asia Region, Thailand
showed 22% for males and 10% for females were alcohol drinking among
adolescents. In WHO Western Pacific Region, there were 17.7% for males and 8.6%
for females in China, and 19.6% for males and 12.9% for females who drank alcohol
in Philippines.
In Vietnam, Kaljee et al. (2005) revealed a significantly greater proportion
of males reported drinking alcohol (40.8%) as compared to female adolescents
(17.5%) (χ2 = 31.6, df = 1, p < 0.00). In other study, Han and Tam (2008) investigated
the prevalence and the factors results in drinking alcohol in students of the Ben Luc
private high school, and the relationship between drinking alcohol and its related factors;
where N = 384 private high school students in Ben Luc district, Long An, province,
Vietnam; the result showed that, there were the differences between males (44.3%) and
females (28.1%) of alcohol drinking. These results had accordance with the result in
the studies of Tho et al. (2007) in Nha Trang, Vietnam.
In conclusion, gender is a factor associated with alcohol drinking behavior. The
present study would like to examine whether male adolescents are more likely to drink
than female adolescents in Ho Chi Minh City or not.
Self-esteem According to Coopersmith (1981), self-esteem indicated the
extent to which the individual believes herself or himself to be capable, significant,
successful, and worthy. Self-esteem is also an important determinant for
psychological well-being that is particularly problematic during the adolescent life
stage (Rosenberg, 1989). Self-esteem has long been considered as an important factor
in individual drinking behavior. Alcoholics have, on the average, exhibited lower self-
esteem than nonalcoholics (Charalampous et al., 1976). Competence skills served as
protective factors; adolescents with higher level of self-esteem could be less likely to
engage in alcohol drinking (Donnelly et al., 2008, Lewis & O’Neill, 2000).
Additionally, Adolescents who begin drinking at a younger age also tend to have
lower self-esteem, be less resistant to peer pressure and display anti-social features
(Flory et al., 2004).
Adolescents experience low self-esteem and frequent self-derogation if they
repeatedly received negative evaluations from conventional others or they feel
deficient in any socially desirable attributes. In defense of their egos, they feel
30 

unwanted, rejected, or deficient in conventionally valued ways might believe that


their self-worth can be enhanced by engaging in alternatives to conventional
behaviors and become involved with deviant peers who boost their sense of self-worth
(Petraitis, Flay, & Miller, 1995). Additionally, the need to belong and feel accepted is
one of the most fundamental human motivations (Baumeister & Leary, 1995). People
with low self-esteem seek interpersonal acceptance from others, presumably as a way
to assuage feeling unaccepted (Vohs & Heatherton, 2001). Kaplan, Martin, and
Robbins (1982) revealed that low self-esteem directly affected involvement of
adolescents with substance-using peers and indirectly affected early experimental
substance use including alcohol consumption. A 30-day daily diary study examined
the relations among implicit self-esteem, interpersonal interactions, and alcohol
consumption in 505 undergraduate predominantly European American college
students (265 females, 240 males) indicated that students with low implicit self-
esteem might unintentionally drink as a way to regulate unfulfilled needs for
acceptance (DeHart et al., 2009). Corbin, McNair, and Carter (1996) examined the
relationship between level of alcohol consumption and self-esteem for 130 male &
130 female undergraduates, and found that for females, as alcohol consumption
increased, self-esteem decreased.
However, there have been other researches that have found no significant
relationship between self-esteem and alcohol consumption among youths. For
example, Karatzias, Power, and Swanson (2001) investigated predicting factors of
smoking, alcohol consumption, and drug use among 425 Scottish adolescent students.
They revealed that self-esteem was not found to significantly predict use or
maintenance of use of substances including alcohol. In a similar vein, Mitic (1980)
found that regular drinking adolescents had higher self-esteem scores than abstinent
adolescents. Additionally, Corbin et al. (1996) also reported that, as alcohol
consumption increased, self-esteem also increased among male undergraduates.
In summary, many studies have trended to support the relationship between
self-esteem and alcohol drinking behavior. However, more research is needed to
understand the association of this factor and alcohol drinking behavior in adolescents
especially in Vietnam. This study will test to see if people with high levels of self-
esteem are less likely to engage in alcohol drinking. The Rosenberg Self-esteem Scale
31 

(RSES), developed by Rosenberg (1979), was used in this study to measure self-
esteem among Vietnamese adolescents.
Academic performance Academic performance is one way to indicate
general intelligence. Intelligence is one of the basic dimensions that characterizes
one’s personality and also contributes to health-related decisions and behaviors. For
instance, more intelligent people may acquire more knowledge about HRBs than less
intelligent people as well as more intelligent people may be less susceptible to the
health-related attitudes and behaviors of other people than less intelligent people (Flay
& Petraitis, 1994).
Several previous studies asserted that problem behaviors such as alcohol and
drug use are significant barriers to educational achievement. Adolescents with higher
academic scores in school were less likely to drink (Balsa et al., 2011; Bergen et al.,
2005; Diego et al., 2003; Kostelecky, 2005; YRBS, 2009). Balsa et al. (2011) studied
7th to 12th grade students in US. (N = 90,118), using data from the National
Longitudinal Study of Adolescent Health. Researchers revealed that increases in
alcohol consumption resulted in small yet statistically significant reductions in GPA
for male students and in statistically non-significant changes for females. For females,
however, higher levels of drinking resulted in self-reported academic difficulty. In
another study, Hayatbakhsh et al. (2010) stated there was inconsistent evidence about
the association between school performance and subsequent use of alcohol and
alcohol problems in adolescents and young adults. Data in this study were from a 21-
year follow-up of 3,478 Australian young adults from birth to the age of 21 years
when data on use of alcohol were collected. The results showed that children who had
lower school performance had increased risk of drinking more than two glasses of
alcohol per day in early adulthood (odds ratio = 1.7; 95% CI = 1.1-2.6).
However, more recent studies have suggested that the association between
alcohol misuse in adolescents and later academic attainment may not be causal
(Chatterji, 2006; Koch & Ribar, 2001). Aertgeerts and Buntinx (2002) investigated
the relationship between academic performance and alcohol drinking behavior; the
results showed that there was no significant association between alcohol abuse and
academic performance in students.
32 

Many studies have trended to support the relationship between academic


performance and alcohol drinking behavior. However, more research is needed to
understand the association between academic performance and drinking behavior
among adolescents.
Drinking refusal self-efficacy The TTI makes the assumption that health-
related self-efficacy is shaped by self-determination or will to control behaviors in
general, and perceptions of personal skills in controlling HRBs in particular. People
who have the will to control their behaviors, and believe they have the skills to
perform a given HRB should have stronger health-related self-efficacy and should be
more likely to decide to adopt health-promoting behaviors (Flay & Petraitis, 1994).
Refusal skills are specific skills frequently indicated as the skills helping adolescents
to engage in less alcohol consumption, making them susceptible to peer pressure, and
giving them greater self-esteem. Many studies revealed that alcohol consumption was
correlated with drinking refusal self-efficacy (DRSE). In one study (Young et al.,
2007), the sample was comprised of 2,020 adolescents ranging from 12 to 19 years of
age (mean age = 14.15), recruited from 14 secondary schools across Queensland,
Australia, the results showed that all three factors reflecting social pressure refusal
self-efficacy, opportunistic refusal self-efficacy and emotional relief refusal self-
efficacy were negatively correlated with both frequency and volume of alcohol
consumption among adolescents. Drinkers reported lower drinking refusal self-
efficacy (DRSE) than non-drinkers [t(1866) = 12.92, p < .001]. Likewise, Oei and
Jardim (2007) also found that DRSE was a significant predictor of alcohol
consumption among Asian and Australian students. DRSE was negatively related to
alcohol consumption. Students with lower DRSE were related to higher alcohol
consumption, [t(92) = 6.32, p < .001]. In other study, using a multiple regression
approach showed that DRSE was associated to amount and frequency of drinking.
Students with low self-efficacy for avoiding heavy drinking reported more alcohol
consumption than others (Gilles et al., 2006).
Moreover, refusal skills appear to be a mediator of the relationship between
general skills and HRBs such as alcohol drinking behavior and have an interaction
between skills to attribute a certain behavior (Flay & Petraitis, 1994). In a study
among inner-city adolescents in New York City (N = 1318), multilevel mixed effects
33 

generalized linear models with random intercept analysis indicated that several
significant interactions were found between refusal skill techniques, decision-making
skills, and perceived social benefits of drinking (Epstein et al., 2007).
In conclusion, a review of the literature suggests that adolescents with low
DRSE are more likely to drink alcohol than those with high DRSE. The Drinking
Refusal Self-Efficacy Questionnaire-Revised Adolescent Version (DRSEQ-RA),
developed by Young, Hasking, Oei, and Loveday (2007), was modified to use in this
study to assess Vietnamese adolescents’ belief in their ability to resist drinking
alcohol.
Attitudinal influence
Attitude towards alcohol drinking In general, behavioral attitudes defined
as the degree to which people hold favorable or unfavorable appraisals toward
behavior, are currently regarded as important predictors of a large variety of human
behaviors (Wallace, Paulson, Lord, & Bond, 2005). People who had the higher the
behavioral attitudinal relevance tended to have the stronger the relationship between
attitudes and behavior (Kim & Hunter, 1993). According to the TTI, the broad
sociocultural factors contribute indirectly to health-related beliefs and attitudes, by
contributing more directly to health-related knowledge, values, expectations, and
evaluations. Substance use is strongly related to both perceptions of personal risks and
personal values. In general, health-related beliefs and personal values converge to
shape attitudes toward HRBs. Additionally; expectations regarding the health,
financial, and social consequences of a given HRB; and evaluations of those
consequences shape most HRBs. An attitude is important predictor of a given
behavior such as alcohol drinking behavior (Flay & Pertraitis, 1994). Epstein et al.
(2007) revealed that students with a high expectation of their friends drinking alcohol
were at increased odds of current drinking than those who had lower expectations
(OR = 7.66, 95% CI = 5.63-10.42). Additionally, several other studies consistently
revealed strong associations between drinking attitudes and alcohol consumption
indicated that the more positive young people's attitudes toward alcohol use, the more
engagement in heavy alcohol use and the higher their drinking levels (Lehto et al.,
1994; Piastrelli et al., 2011; Stacy et al., 1994).
34 

Brook and Tepper (2002) studied about the consumption, knowledge and
attitudes towards alcohol use and alcohol dependence among 512 high school pupils
in Holon City, Israel. The findings showed that adolescents who had a lack of
knowledge about alcohol use tended to be related to an increased likelihood of
drinking, adolescents who had more positive attitude towards drinking had tended to
be related to an increased likelihood of drinking. Similarly, the results in a study in
Netherlands indicated that participants' attitudes toward alcohol showed positive
associations with the alcohol consumption (Roek et al., 2010). Promarak and
Laohasiriwong (2011) examined factors influencing alcohol use disorder among 878
first year students of Mahasarakham University, Thailand. The result showed that
attitude on alcohol use disorder control was factor statistically significant influencing
alcohol use disorder among students (OR = 2.64, 95% CI = 1.81-4.64). In another
study in Eastern of Thailand, Homsin and Srisuriyawet (2010) studied factors related
to alcohol drinking behavior among Thai youths (n = 887). The findings indicated that
attitude towards alcohol drinking was significantly associated with all stages of
alcohol drinking, for instance, at the susceptible precontemplation stage (OR = 1.09,
95% CI = 1.05-1.13), the tried stage (OR = 1.08, 95% CI = 1.05-1.12), and the
experimentation stage (OR = 1.16, 95% CI = 1.12-1.20).
Overall, several studies consistently revealed strongly associations between
drinking attitudes and alcohol consumption indicating that the more positive
adolescents’ attitudes toward alcohol use, the more adolescents engage in alcohol
consumption. The Alcohol Drinking Attitude Scale developed by Homsin and
Srisuriyawet (2010) was modified to measure attitude towards alcohol drinking
among adolescents in this study.
Interpersonal influences
Family structure Several previous studies have widely underlined the
contribution of family factors on teenage drinking. Adolescents from one-parent or
stepparent families are at higher risk for alcohol problems because of the stress
induced by parental conflict, lower income or other sociodemographic correlates.
Previous studies (Hong et al., 2010; Jablonska & Lindberg, 2007; Yeh & Chiang,
2005) showed that parental marital status had consistently been found to predict
adolescent alcohol consumption, with youth from single-parent families showed more
35 

alcohol use than youth from two-parent families. Yeh and Chiang (2005) indicated
single-parent family was a significant predictor of alcohol consumption among Han
adolescents in Taiwan (OR = 2.12, 95% CI = 1.26-3.59). Htay et al. (2010) also
showed that adolescents living with a single parent were all significantly associated
with a higher likelihood of alcohol use and frequent binge drinking. These results
were in accordance with the results in study of Svensson (2010) in Sweden.
In summary, adolescents who live with both mother and father are less likely
to drink alcohol than others. Family structure is presumably considered to be the
factor related to alcohol drinking in this study.
Parental monitoring Parental monitoring is also a significant factor
associated to alcohol drinking behavior among adolescents. The results from the
studies (Breen et al., 2010; McCoy et al., 2010; Schulte et al., 2009) showed that
parental monitoring was negatively related to levels of alcohol use among
adolescents. Begue and Roche (2009) conducted a survey of 1,295 students between
14 and 19 years old in Grenoble City, France. Results of logistic regression analysis
indicated that parental monitoring was negatively significant to predict use of alcohol
among adolescents (OR = 0.83; 95% CI = 0.70-0.98). This result was accordant with
the result in the study of Freisthler, Byrnes, and Gruenewald (2009) in the U.S. In
another study, researchers concluded that parental monitoring showed a protective
effect on growth in volume of alcohol consumption by high school students.
Increasing levels of parental monitoring over time was associated with less growth
across the high school years (Capaldi et al., 2009). Thus, it has been posited that
parental monitoring is mainly driven by adolescent disclosure, which certainly is part
of the overall monitoring process (Stattin & Kerr, 2000). A study of adolescents in
South Korea by Kim et al., (2010) revealed that there was a negative relationship
between parental attachment and supervision and adolescent substance (alcohol and
tobacco) use. It indicated that as parental attachment and supervision increased the
frequency of substance use in adolescents decreased. Tobler and Komro (2010)
showed that students with high monitoring from parents were more likely to decrease
in alcohol consumption (OR = 3.29).
36 

In conclusion, the parental monitoring is negatively related to levels of


alcohol use among adolescents. The parental monitoring is paid more attention in the
present study.
Parental drinking Several evidences revealed that paternal drinking was a
very important factor related to alcohol drinking among adolescents. Adolescents
were more likely to drink if their parents drink (Koning et al., 2010; Mares et al.,
2011; Scholte et al., 2008; Yang & Schaninger, 2010). In another study, Capaldi et al.
(2009) indicated that alcohol use by parents was associated with initial levels of
alcohol use and volume among boy adolescents. Yeh and Chiang (2005) studied on
771 of 10th-grade students in Hualien and Taitung, Taiwan indicated that paternal
drinking was positive related with adolescents’ alcohol consumption (OR = 6.48, 95%
CI = 2.19-19.18). Similarly, there was a high risk of alcohol consumption among
students and youths in Yangon, Myanmar because of their parents’ drinking (OR =
2.9, 95% CI = 1.6-5.0) (Htay et al., 2010).
Overall, paternal drinking is a very important factor related to alcohol
drinking among adolescents. Adolescents are more likely to drink if their parents
drink. Therefore, parental drinking is a factor influencing alcohol drinking behaviors
in this study.
Peer drinking Friends are considered to be important role models in
adolescents’ peer contexts, these peer influences on adolescent alcohol consumption
over time (Poelen et al., 2007). Researchers suggested that adolescents may be more
likely to engage in alcohol use and other drugs when close friends or other peers
engage in similar behaviors (Han & Tam, 2008; Kim et al., 2010; Mays et al., 2010;
Svensson, 2010). Peer group was a very important predictor associated to alcohol
drinking behavior among adolescents. Poelen et al. (2007) examined the relative
impact of alcohol use of the best friends on the development of alcohol consumption
during adolescents (N = 416, aged 13-16 years) in the Netherlands, the results showed
a strong similarity in drinking between best friends and adolescents. Scholte et al.
(2008) found similar results. According to the study of Mays et al. (2010) there was a
significant association between alcohol-related behaviors and perceived peer drinking
among adolescents in Georgia, Muscoge.
37 

Newman and Innadda (1999) studied alcohol use among adolescents in


Chonburi, Thailand showedand found that most adolescents drank with their friends
(80.6% of the males and 60.3% of the females). In the study of Yeh and Chiang
(2005) in Taiwan indicated that if peers drank frequently, odds ratio was 6.26 times
likely for adolescents to have alcohol-related negative consequences. In Myanmar,
about 71.2% of male students had exposure to drinking habits of their friends who
drank, and 27.6% experienced peer pressure to drink (Htay et al., 2010). In another
study in US, the findings indicated that alcohol use by peers was associated with
initial levels of alcohol use and volume among adolescents (Capaldi et al., 2009).
In Khanh Hoa, Vietnam, Kaljee et al. (2005) investigated perceptions of
peers’ alcohol consumption among 480 Vietnamese youths from 15 to 20 years old.
They found that overall drinkers and those reporting intoxication perceived that more
of their friends drank when compared to non-drinkers (χ2 = 42.4, df = 2, p < 0.00/ χ2 =
7.6, df = 2, p < 0.02). In addition, alcohol users (χ2 = 21.3, df = 4, p < 0.00) and males
(χ2 = 19.1, df = 2, p < 0.00) were also significantly more likely to intend to drink with
friends in the next 6 months. In Long An, Vietnam, Han and Tam (2008) showed that
adolescents usually drank with friends, such as their classmates.
In summary, a review of the literature suggests that adolescents are more
likely to engage in alcohol use when close friends or other peers engage in similar
behavior. Therefore, peer drinking remains as an important factor that will be
explored in the present study.
Perceived alcohol availability Perceived availability is commonly
associated with adolescent alcohol use. Adolescents who have a variety of
opportunities to obtain alcohol may develop the impression that underage drinking is
common and socially endorsed (Kuntsche, Kuendig, & Gmel, 2008). Commercial and
public availability of alcohol can have a reciprocal influence on the social availability
of alcohol and thus contribute to changing social and cultural norms that promote
harmful use of alcohol (WHO, 2010). Availability of alcohol can be determined by
policies that specify who can consume alcohol, where it can be consumed, how and
where alcohol is distributed and sold, and policies that affect the price of alcohol
(WHO, 2009; 2011 c).
38 

Alcohol availability is an environmental factor that is known as a risk factor


related to an increase in alcohol drinking behavior in adolescents (Dent et al, 2005;
Jones et al., 2011; Weitzman et al., 2003). Adolescents can obtain alcohol from a
wide range of commercial sources such as convenience and grocery stores or from
friends, parents or other social sources (Kreda, Joel Grube, & Paschall, 2010;
Paschall, Grube, Black, & Ringwalt, 2007). The WHO (2004 c) showed that alcohol
resource service was a significant factor related to alcohol use and alcohol related
problem. According to Campbell et al. (2009), alcoholic beverage outlet density
referred to the number of physical locations in which alcoholic beverages were
available for purchase either per area or per population. Most of the studies included
in the review of Campbell et al. (2009) found that greater outlet density is associated
with increased alcohol consumption and related harms, including medical harms,
injury, crime, and violence. Chen et al. (2009) also showed that alcohol outlet density
was significantly and positively related to the initial levels of the likelihood and
frequency of getting alcohol through various sources including commercial outlets,
home or family members, and underage acquaintances, indicating that high density
levels of alcohol outlets in the community enable youths to access alcohol through
commercial outlets, family, and social networks. Similarly, in a study of 1894 U.S.
college students (aged ≤ 19 years) (Weitzman et al., 2003), which used univariate and
multivariate logistic regression analyses indicated that students who reported
exposure to “wet” environments (wet environments included social, residential, and
market surroundings in which drinking is prevalent and alcohol cheap and easily
accessed) were more likely to engage in binge drinking than were their peers without
similar exposure. Students reported that it was very easy to obtain alcohol; and that
they had procured alcohol from either a peer of legal drinking age or from a bar,
liquor store without age identification were more likely to binge drink than their peers
who found it harder to procure and/or were without a network or purchase sources
(OR = 1.76; 95% CI = 1.27-2.41).
Dent et al., (2005) studied 16,694 students, aged 16-17 in 92 communities in
Oregon. A multi-level analysis indicated that the rate of illegal merchant sales in the
communities directly related to frequency of alcohol use, binge drinking, and alcohol-
related problems. There was also evidence that communities with a higher minimum
39 

drinking age or those which had more effective law enforcement had lower rates of
alcohol use and binge drinking. The use of various sources of alcohol in a community
either expanded or contracted depending on levels of access and enforcement. This
evidence provides empirical support for the potential utility of local efforts to
maintain or increase enforcement to control alcohol access and possession. Moreover,
the price of alcohol and alcohol advertising are also related to alcohol consumption
among adolescents (WHO, 2011 c). Cheap or discounted alcohol was related to an
increase in the uptake of binge drinking (OR = 4.38; 95% CI = 2.95-6.56) (Weitzman
et al., 2003). A recent review of 112 studies of the effects of alcohol tax/ price
affirmed that when alcohol taxes went up, drinking went down, including among
problem drinkers and youths. Meta-analytical results document the highly significant
relationships (p < 0.001) between alcohol tax or price measures and indices of sales or
consumption of alcohol (aggregate-level r = -0.17 for beer, -0.30 for wine, -0.29 for
spirits and -0.44 for total alcohol) (Wagenaar, Salois, & Komro, 2009).
The WHO (2008, 2011 c) suggested some strategies to reduce alcohol
availability, for example, restriction of sales and consumption by people below a legal
drinking age; control of alcohol distribution and sales; regulation on the hours and
days of the sale of alcohol; increasing the price of alcohol; control of alcohol
advertising and marketing. An example of the regulation of alcohol is the
comprehensive control in Thailand through alcohol policies, for example, the Thai
Health Promotion Foundation (ThaiHealth) is an autonomous state agency, which was
established in 2001 as the first organization to use alcohol excise taxes for health
promotion in Asia. ThaiHealth supports the establishment of an enforcement
surveillance center for alcohol control regulations, and a research center on alcohol
consumption. It has also paid for advertising campaigns to reduce alcohol-related
traffic accidents, to encourage abstinence and to raise awareness of the links between
alcohol and domestic violence. ThaiHealth has helped persuade the government to
pass a national policy to control alcohol advertising and to establish a National
Committee for Alcohol Consumption Control. Drinking alcohol is still allowed in
Thailand. However, people cannot buy alcohol at all times of a day. Shops like
supermarkets and 7-Elevens are not allowed to sell alcohol between 2.00-5.00 P.M.
and after midnight. On given days (religious and national holidays, election days),
40 

alcohol sales are banned altogether, and drinks cannot be served even in restaurants
and bars (which usually close on these days anyway). The legal minimum age to
purchase alcohol is until very recently 20 years (Thaiwebsites, 2010; WHO, 2011 c).
In summary, alcohol availability including alcohol resource service, alcohol
outlet density, legal alcohol drinking age, and price of alcohol are related to alcohol
drinking behavior in adolescents.
From the evidence presented and discussed in this chapter, it is expected that
the results from this study will improve understanding about the association between
alcohol drinking behavior among adolescents and studied factors including age,
gender, self-esteem, academic performance, drinking refusal self-efficacy, attitude
towards alcohol drinking, family structure, parental monitoring, parental drinking,
peer drinking, and perceived alcohol availability. Thus it enhances the development of
strategies for preventing and reducing alcohol consumption for adolescents and
reducing negative consequences related to adolescent alcohol drinking in the future.
To help clients to achieve optimal health and well-being means that the roles and
nursing strategies of community nurses should expand to include care for those
adolescents at risk.

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