The European Journal of Public Health Advance Access originally published online on May 23, 2007
The European Journal of Public Health 2008 18(1):12-18; doi:10.1093/eurpub/ckm038
Your Health |
Individual, group and community risk and protective factors for alcohol and drug use among Swedish adolescents
Richard Bränström, Elisabet Sjöström and Sven Andréasson** Department of Public Health Sciences at the Karolinska Institute, Stockholm, Sweden
Correspondence: Richard Bränström, Department of Public Health Sciences at the Karolinska Institutet, STAD, Crafoords väg 6, SE - 113 24 Stockholm, Sweden, tel: +46 8 737 51 16, fax: +46 8 737 51 07, e-mail: richard.branstrom{at}ki.se
Received January 12, 2007, accepted March 25, 2007
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Background: A number of factors have been identified that protect adolescents or, alternatively, put them at risk for drug use and other high-risk behaviours. These factors concern different personal and environmental factors, e.g. the community, the school setting, family, peer group and individual characteristics.The aim of the present study was to examine the associations between risk and protective factors and adolescents’ use of alcohol and drugs. Methods: In both May 2003 and 2004, random samples of 4800 adolescents (a total of 9600) in Sweden were contacted and asked to fill out a questionnaire.It concerned use of alcohol and illicit drugs and a large number of adolescent risk and protective factors. A total of 5445 (57%) adolescents agreed to participate. Results: About 44% of the adolescents in grade 9 (15–16 years of age) had been drunk on at least one occasion and nearly 80% of those in grade 11 (17–18 years of age). Almost 15% in grade 9 and 40% in grade 11 had been drinking heavily during the previous month, and 4% in grade 9 and 12% in grade 11 had used cannabis. Strong associations were found between elevated individual, family, school and community risk factors and use of alcohol and drugs. Conversely, protective factors were negatively related to the use of alcohol and drugs. Conclusions: This study confirms the importance of risk and protective factors within different domains in explaining alcohol and drug use among adolescents. The results support efforts targeting multiple risk and protective factors in alcohol and drug preventive interventions for adolescents.
Keywords: adolescents, alcohol, drugs, prevention, protective factors, risk factors
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The use of alcohol and other drugs is a major contributor to social problems and ill health globally.1 Since an early start to alcohol and marijuana use seems to be related to an increased risk of alcohol dependency later in life, adolescents and young adults’ alcohol and drug use has been of special interest to researchers and public health workers.2,3 In addition to the onset of drinking, the pattern of consumption of alcohol is of concern and, in particular, heavy episodic drinking. Frequent high alcohol consumption and binge drinking in adolescence are risk factors for future alcohol dependence and increase the likelihood of several other health hazards such as bodily injury, traffic accidents, violence, drunk driving and marijuana use.4–7 Injuries are the most severe health threat to adolescents and the leading cause of death in the adolescent ages.8,9 Another area of concern is adolescent use of cannabis, which has been linked to an increased risk of schizophrenic disorders and other mental health conditions such as anxiety and depression.10,11 Cannabis has also been cited as a ‘gateway’ drug, i.e. as an introduction to a pathway leading to the use of more serious and health-impairing drugs.
A number of factors have been identified that can protect adolescents, or put them at risk for and increase their vulnerability to alcohol abuse, drug abuse and other high-risk behaviours. These factors have been presented as a risk and protective factor model.12 A substantial part of the research and intervention developments during the past decade has been influenced by this model. The risk and protective factors can help to explain adolescent behaviour and facilitate preventive efforts. They can be grouped in different domains, such as the broader community, the school setting, family situation, peer group and individual characteristics. For example, several studies have shown that living in an unsafe community, having a low degree of attachment to school, belonging to a peer group with positive attitudes towards norm-breaking behaviour and having such personal characteristics as high impulsiveness increase the likelihood of alcohol and drug abuse 12–14. The rationale for identifying risk factors for alcohol and drug use among adolescents is to promote effective preventive interventions. These interventions should be aimed at reducing or eliminating risk factors and increasing protective factors. Using a risk and protective factor approach is one way of increasing awareness of the need for preventive efforts targeting adolescents and young adults. It provides public health planners with information about which aspects of youth development in young people to target with preventive efforts. The aim of the present study was to examine the associations between a number of risk and protective factors and adolescents’ use of alcohol and drugs in a national Swedish sample.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Participants
In both May 2003 and May 2004, age- and gender-stratified samples of 4800 randomly selected adolescents (2400 15–16 years old (school grade 9) and 2400 17–18 years old (school grade 11)) from 12 different municipalities in Sweden were sent a letter asking them to fill out an enclosed questionnaire. The addresses were taken from the Swedish census registry. In the case of respondents under the age of 16, the questionnaire was sent to the respondent's parents who were asked to pass on the enclosed questionnaire to their child. Two reminders were sent to those not responding, and the second reminder included a new questionnaire. No financial compensation for participation was given. In 2003, 2803 questionnaires (55%) were returned, with 1577 (66%) of the girls and 1226 (51%) of the boys returning their questionnaire. In 2004, 2642 questionnaires (55%) were returned and 1508 (63%) of the girls and 1134 (47%) of the boys returned their questionnaire. A total of 5445 adolescents are included in the analysis in this article.
Measures
Background questions
The respondents were asked to indicate their gender and age and their parents’ level of education and occupation. The respondents indicated the level of education of both the mother and the father in response to two questions with four response alternatives relevant to Swedish conditions. One open alternative was provided where educational backgrounds not listed could be recorded. The responses were then coded into three categories according to the parent with the highest level of education, i.e. university degree, high school degree, or elementary school.
Alcohol and drug use
The participants were asked if they had ever been intoxicated with alcohol. The average consumption during the last 12 months was also assessed for different types of alcohol, i.e. beer, wine, liquor and cider. One question was asked about the frequency of intensive alcohol consumption (at least one bottle of wine or its equivalent, being equal to ‘5+ drinks’) during the last 12 months. Participants were also asked if they had ever used cannabis or other illicit drugs, namely ‘Have you ever used cannabis?’ and ‘Have you ever used any illicit drugs other than cannabis?’
Risk and protective factors
Risk and protective factors were assessed by a number of questions concerning school environment, family climate, peer behaviour, and individual characteristics. The questions had previously been used in other Swedish studies on adolescent risk and protective factors.15 The questionnaire included 15 measures or scales concerning risk factors and 11 measures or scales concerning protective factors (table 1).
|
Definition of elevated risk or protective factor
Risk and protective variables were measured on scales that consisted of several items, e.g. perceived availability of alcohol and drugs, low self-perceived school ability, and frequent arguments and fights, and elevated risk or elevated protection, were defined as those in the upper third of the distribution of scores on the items. For measures using single-item assessments of a risk or protective factor, elevated risk or elevated protection was defined in terms of having or not having reached a specified criterion. The criteria for each single-item measure are presented in table 1. A score was calculated for each individual based on the number of elevated risk factors and the number of elevated protective factors.
Statistical analyses
The statistical analyses were made with the SPSS statistical package.16 Both univariate and multivariate logistic regression analyses were conducted to estimate the association of sociodemographic, risk and protective factors with alcohol and drug use. Due to the large sample size, and in order to minimize the risk of identifying random associations, an alpha value of 0.01 was regarded as significant.
Non-response study
Most questionnaires were returned within the first 2 months. But as nearly 40% of the total sample did not respond, a follow-up non-response study was conducted. Six months after the initial questionnaires were mailed, a second shorter version of the questionnaires was sent to a random sample of 1000 of the adolescents that had not responded to the initial questionnaire. The questionnaire included items on background factors, alcohol use and use of cannabis. A total of 377 adolescents (38%) responded to the questionnaires. There were no differences between initial responders and initial non-responders among the 11th graders. Among the 9th graders, heavy use of alcohol was much more frequent among the initial non-responders.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Frequency of alcohol and drug use
The associations between alcohol and drug use and sociodemographic variables are presented in table 2. Sixty percent of the boys and 63% of the girls had been intoxicated with alcohol at least once. The gender difference was not significant, but there was a significant difference in the percentage of adolescents who had ever been intoxicated with alcohol between 9 and 11 graders with those in 11th grade having been intoxicated more often (P < 0.001). The adolescents that live with only one parent or those living with two parents at separate locations were more likely to have been intoxicated. The adolescents whose parents were both unemployed were less likely to have been intoxicated.
|
Nearly one-third of the adolescents had drunk heavily (i.e. at least one bottle of wine or equivalent) monthly. Those in grade 11 were much more likely to be drinking heavily on a monthly basis than 9th graders. Living with only one parent increased the risk of intensive alcohol consumption.
About 4% of the adolescents in school grade 9 had used cannabis on at least one occasion. Twelve percent of those in school grade 11 had used cannabis. Cannabis use was more common among those living with only one parent and less common among those with parents who had a medium level of education.
Alcohol and drug use related to exposure to multiple risk and protective factors
The scale for each risk and protective factor was dichotomized with those at elevated risk or protection coded as 1 and the rest as 0. To assess the impact or multiple risk and protective factor, scores were calculated by summing up the scales for risk and protective factors. The association between these scores and alcohol and drug use is illustrated in figure 1. The percentages are presented separately for females and males and separately for 9th and 11th graders. A larger number of risk factors increased the likelihood of having ever been drunk, of intensive monthly alcohol consumption, and of having used cannabis. The number of protective factor was negatively related to all three behaviours. The pattern of associations was very similar between males and females.
|
Multivariate analysis of alcohol and drug use
When both background factors and risk and protective factors were entered into a multiple logistic regression analysis with a forward inclusion approach, the overall strongest associations were found for a number of different risk and protective factors and use of alcohol and drugs (table 3). In grade 9, delinquency among boys and positive attitudes alcohol and tobacco among girls were the factors most strongly correlated with ever having been drunk. Other strong predictors included parents offering alcohol, perceived availability of drugs, truancy and having norm-breaking friends. A positive attitude towards restrictions was the most important protective factor against ever having been drunk, along with alcohol problems in the family for the girls. For students in grade 11, the pattern looked somewhat different. The most important predictors for ever having been drunk were a positive attitude towards alcohol, parents providing their adolescent children with alcohol, and perceived availability of alcohol. Protective factors were a positive attitude to restrictions, high self-perceived school ability among boys, and having a curfew for girls.
|
Rather different patterns of association were found for adolescents’ intensive consumption of alcohol by adolescents. Among 9th graders, monthly intensive consumption of alcohol was associated with a positive attitude to alcohol and to socialize with norm-breaking friends. Furthermore, truancy and cheating in exams were also predictive factors for heavy drinking among boys in school grade 9, as were perceived availability of drugs and alcohol among girls. In the older age groups, a positive attitude to alcohol, alcohol availability, and parents providing alcohol to adolescents were important risk factors for both boys and girls. For girls, truancy and having norm-breaking friends were also predictive factors for heavy drinking.
Cannabis use was associated with fewer risk and protective factors than alcohol use. For both boys and girls in both age groups, a positive attitude toward drugs, perceived availability of drugs and norm-breaking behaviour or antisocial friends were the predominant predictors of cannabis use. No protective factors were associated with cannabis use.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
This is, to our knowledge, the first national study of risk and protective factors conducted with a random sample of adolescents in Sweden. As this study was not school-based, respondents were recruited among both those going to school and those not going to school. There is also a growing interest in risk and protective factors for alcohol and drug use from both researchers and practitioners in Sweden as well as internationally. The interest in risk and protective factors is probably due to their potential to throw light on the patterns in the adolescents’ situation and a number of health hazards and problems. There is growing evidence showing that similar antecedents predict multiple problem behaviours among adolescents.13 That makes this an important tool for researchers in communicating with practitioners and policy-makers involved in local prevention. In this study, we found strong support for the association between risk and protective factors and alcohol and cannabis use. Furthermore, the association appears to become stronger with an increasing number of risk and protective factors. It also seems that the same factors may partially explain both alcohol and drug use. However, for adolescent cannabis use the protective factor does not appears to be as important as the risk factors. It seems as if the general finding of increased alcohol and cannabis use among those with a larger number of risk factors is true for both boys and girls. These findings are in line with earlier studies12 and should be considered in the planning and development of preventive interventions and strategies.
Apart from showing a strong association between the number of risk and protective factors and drug use, this study indicates a number of specific factors of special concern in explaining adolescent alcohol and drug use. It becomes clear that a number of factors are important to explain why some adolescents indulge in heavy alcohol consumption and others do not. Most important seems to be the adolescent's attitudes toward alcohol, drugs and restrictions. However, nearly equally important are the perceived availability of alcohol and drugs and, in particular, parents offering alcohol to their adolescent children. These findings give a clear message to policy-makers and suggest preventions concerning the focus of preventive action. A decreased availability of alcohol especially from parents could potentially decrease the number of drunk and intensive alcohol-consuming adolescents. Having a restrictive policy toward offering alcohol to one's child seems to be equally important for younger and older adolescents, and especially important for girls.
Peer group pressure seems to be important for both alcohol and drug use among adolescents. Especially for the younger age group, aged 15–16. Having antisocial friends was predictive of the use of cannabis among 15–16 year-old boys, and among girls and boys in school grade 11. But it was not associated with use of alcohol. The use of cannabis is illegal in Sweden, and this seems to make this drug more common among those involved in criminality or at least among those with criminal acquaintances. Having norm-breaking friends, however, seems to predict both alcohol and cannabis use among girls. Among boys, having norm-breaking friends was only predictive of alcohol use and only among the young boys. A strong association between peer group use of drug and norm-breaking behaviour, and drug use has been demonstrated in previous studies.13,14 Our study indicates that preventive interventions targeted at the effects of peer groups on drug use should especially target girls as well as boys in early adolescence.
Other significant patterns that emerged in the analysis were the importance of a positive attitude to restrictions and preventive activities. Having a positive attitude seemed to decrease both the likelihood of having ever been drunk and the likelihood of monthly intensive consumption of alcohol. Corresponding findings were found in a study from the US where anti-smoking attitudes were predictive of less heavy smoking among girls.17 Another important finding was that girls in grade 11 were less likely to have ever been drunk and to have consumed alcohol intensively if they had a curfew for returning home. This should be emphasized in preventive messages to parents.
Generally speking, the same predictors appear to be important for explaining drug use among both boys and girls. A US study of predictors use of drugs of adolescents aged 12–18 years showed that gender differences were most important at younger ages, and that the same predictors seem to be important for adolescents over 12–13 years of age.14
Research examining the development of antisocial behaviour in a life-course perspective has demonstrated an association between childhood onset of delinquent behaviour and alcohol use with high-risk individual factors such as neurocognitive problems, impulsiveness and problems related to attention deficits.18,19 This could not be confirmed in our study, as few individual factors remained as significant predictors in the multivariate analysis when school, family and community risk and protective factors were entered into the equation.
An interesting finding that comes out in this study was that socioeconomic status and family situation did not significantly predict drug use when both background and risk and protective factors were entered in the multivariate analysis. Some risk and protective factors seem to be more important in predicting drug use than background factors. This is a positive result for prevention since, at least in theory, it should be possible to change most risk and protective factors. These findings strengthen the notion that risk and protective factors should be targeted in preventive actions to decrease drug use among adolescents.
Limitations of the study
Although the present study has extended previous work by examining the predictive value of risk and protective factors in alcohol and drug use among adolescents, it is not without several limitations. Even though we used a random sample from the population and the response rate in this study was similar to those in comparable questionnaire studies, we have only a limited amount of knowledge about the difference between respondents versus non-respondents. However, the follow-up study of a random sample of the non-respondents indicated that 9th graders not responding initially were somewhat more likely to be intensive consumers of alcohol. These differences could be explained in two ways: either the alcohol use among adolescents in grade 9 had increased a lot during the 6-month period, or non-responders are more frequent heavy alcohol users. However, no differences were found in cannabis use among respondents and non-respondents. If this is a result of a biased selection of respondents, it might not be possible to generalize the results from this study to the whole adolescent population. Perhaps other factors are important in predicting hard-to-reach adolescents’ alcohol and drug use.
A further limitation is the cross-sectional design of the study, especially since the aim was to analyse potential causal relationships. It is not possible to draw causal conclusions based on cross-sectional data and thus the relations between variables presented in this study must be regarded as describing associations rather than causal patterns.
Future directions
Even though the results presented in this study show very strong associations between risk and protective factors and drug use, there is still a need to develop new explanatory factors for adolescent risk behaviours. The model presented in this study explains some of the variance in alcohol and drug use, but much remains unexplained. New explanatory factors should be developed and especially more protective factors should be identified, which might increase our understanding and give further guidance for prevention.
|
Acknowledgements |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The Swedish Council for Working Life and Social Research and the National Institute of Public Health supported this research.
Conflicts of interest: None declared.
Key points
|
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
1 The World Health Organisation. Global Status Report on Alcohol 2004 (2004) Geneva.
2 Grant BF, Stinson FS, Harford TC. Age at onset of alcohol use, & DSM-IV alcohol abuse and dependence: a 12-year follow-up. J Subst Abuse (2001) 13:493–504.[CrossRef][Web of Science][Medline]
3 Bonomo YA, Bowes G, Coffey C, Carlin JB, Patton GC. Teenage drinking and the onset of alcohol dependence: a cohort study over seven years. Addiction (2004) 99:1520–8.[CrossRef][Web of Science][Medline]
4 Bonomo Y, Coffey C, Wolfe R, Lynskey M, Bowes G, Patton G. Adverse outcomes of alcohol use in adolescents. Addiction (2001) 96:1485–96.[CrossRef][Web of Science][Medline]
5 Gmel G, Rehm J. Harmful alcohol use. Alcohol Res Health (2003) 27:52–62.[Web of Science][Medline]
6 Windle M. Alcohol use among adolescents and young adults. Alcohol Res Health (2003) 27:79–85.[Web of Science][Medline]
7 Christopherson TM, Jordan-Marsh M. Culture & risk taking in adolescents' behaviors. MCN Am J Matern Child Nurs (2004) 29:100–5.[CrossRef][Medline]
8 Paulson J. The epidemiology of injuries in adolescents. Pediatr Ann (1988) 17:89–96.
9 Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students age 18–24: changes from 1998 to 2001. Annu Rev Public Health (2005) 26:259–79.[CrossRef][Web of Science][Medline]
10 Andreasson S, Allebeck P, Engstrom A, Rydberg U. Cannabis and schizophrenia. A longitudinal study of Swedish conscripts. Lancet (1987) 2:1483–6.[Web of Science][Medline]
11 Raphael B, Wooding S, Stevens G, Connor J. Comorbidity: cannabis and complexity. J Psychiatr Pract (2005) 11:161–76.[CrossRef][Medline]
12 Hawkins DJ, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychological Bulletine (1992) 112:64–105.[CrossRef]
13 Barnes GM, Welte JW, Hoffman JH, Dintcheff BA. Shared predictors of youthful gambling, substance use, and delinquency. Psychol Addict Behav (2005) 19:165–74.[CrossRef][Web of Science][Medline]
14 Barber J, Bolitho F, Bertrand L. Intrapersonal versus peer group predictors of adolescent drug use. Children and Youth Services Review (1999) 21:565–79.[CrossRef][Web of Science]
15 El-Khouri BM, Sundell K, Strandberg A. Riskfaktorer för normbrytande beteenden: Rapport 2005:17 (2005) Stockholm: FoU-enheten Stockholms stad.
16 SPSS Inc. SPSS Base 8.0. 8.0 ed. Chicago: SPSS Inc. 1999.
17 Griffin KW, Botvin GJ, Doyle MM, Diaz T, Epstein JA. A six-year follow-up study of determinants of heavy cigarette smoking among high-school seniors. J Behav Med (1999) 22:271–84.[CrossRef][Web of Science][Medline]
18 Moffitt TE, Caspi A. Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Dev Psychopathol (2001) 13:355–75.[CrossRef][Web of Science][Medline]
19 Eklund J. Adolescents at risk of persistent antisocial behaviour and alcohol problems: the role of behaviour, personality and biological factors (2006) Stockholm: Stockholm University/Karolinska Institutet.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||