Native Hawaiian Mental Health Research Development Program (NHMHRDP), Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
Received 9 March 2000; in revised form 12 November 2000; accepted 15 December 2000
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ABSTRACT |
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INTRODUCTION |
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For the culturally diverse population of Hawaii, the adult prevalence rates of ~56% for alcohol dependency and 2.53% for alcohol misuse are much higher than the dependency misuse rates of marijuana, cocaine, hallucinogens, heroin, and amphetamines (Office of Hawaiian Affairs, 1998). In the case of adolescents, 20.2% of females and 27.9% of males indicated that they had five or more successive drinks of alcohol within a couple of hours within the past 30 days (Office of Instructional Services/General Education Branch, 1995
). These rates for adolescents are generally lower than the national figure of 32.6% (Pateman et al., 1996
). However, it was found that Native Hawaiians use more alcohol than the other major non-Caucasian ethnic groups residing in Hawaii (Danko et al., 1988; Deck and Nickel, 1989; see also the review by Hishinuma et al., 2000), and have higher rates of problem drinking which include both acute (binge) and chronic drinking (Johnson et al., 1998
; Office of Hawaiian Affairs, 1998
), with rates of alcohol use also being high for Caucasians who live in Hawaii (see Alu Like, Inc., 1985; Takeuchi et al., 1987; and the review by Hishinuma et al., 2000).
Studies of the incidence of alcoholism in Hawaii suggest that different ethnic groups may have widely divergent standards regarding the quantities and behaviours defining alcohol misuse (Ahern, 1989). Cultural norms are important determinants of the level of alcohol use and the probability of risks of alcoholism (Johnson et al., 1987
). These latter authors found that the cohesive system of social norms and sanctions in ethnic groups provided an obvious source for alcohol-use norms. However, the values and norms of the family, spouse, and friends may diverge from the respective ethnic-group norms and these individualized characteristics may have a more direct influence on alcohol-related behaviours. In examining alcohol use in the context of the reasons for either drinking or not drinking, Johnson et al. (1985) found that a stronger predictor of present alcohol use was group affiliation based on past use (e.g. abstainers, past drinkers) as compared to groups based on ethnicity.
Risk and protective factors have not been sufficiently investigated for minority populations (Jenkins and Parron, 1995), including those for alcohol use in Native Hawaiians. This type of research has become increasingly important in the light of the significant growth in the proportion of Asian/ Pacific Islanders (Barringer et al., 1993
) and the short- and long-term negative impact alcohol can have on adolescents. Therefore, the present study examined the association between alcohol use and predictors by grouping the risk and protective factors into four categories: (1) demographic; (2) person or self; (3) family; (4) friends.
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SUBJECTS AND METHODS |
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Measures
All measures were part of the Hawaiian High Schools Health Survey (HHSHS) that was administered to the participants.
Demographic variables.
Five demographic factors were included: (1) ethnicity (1 = Hawaiian versus 2 = non-Hawaiian); (2) gender (1 = male, 2 = female); (3) grade level (9th12th); (4) main-wage earners' educational level (scale of 17; see Table 1); (5) self-reported last-report-card grades. The latter was operationized using the following question: On average, what were your grades on your last report card? The following choices were available (values in parentheses are the quantification of the grade variable; these values did not appear on the questionnaire): A (4.0), A (3.7), B+ (3.3), B (3.0), B (2.7), C+ (2.3), C (2.0), C (1.7), D or less (1.0), or Don't know (missing score).
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For all four measures, higher scores indicated a greater degree of symptomatology or distress. When not more than one-fourth of the items of either the CES-D, STAI or BADS were incomplete for a given respondent, adjustments to the composites were accomplished based on the average Z-score difference for the items within a scale. This procedure takes into account both the individual participant's score on all non-missing items and the mean of the group in deriving an adjusted composite for the participant. In addition, the CES-D and STAI contained reversed items on the scale. This allowed for a form of validity check. Scores were not included for participants who responded (on either the CES-D or STAI scale) with all 20 ratings being either the lowest or highest possible rating prior to reverse scoring.
Family variables.
The four dimensions in this domain were as follows: (1) Perceived Social Support From Family (PSS-Family; Procidano and Heller, 1983): This measure is composed of six items each rated on a 15 scale (with one reversed statement); the higher the score, the greater the amount of perceived family support. (2) Major Life Events for family members (Andrews et al., 1993): This instrument consists of 13 of 14 items related to negative stressful events occurring within the past 6 months (e.g. death, arrests, suicide attempt) as rated by the adolescent. (3) Family members and alcohol/drug use: The remaining item (Had problems with drugs or alcohol) from the Major Life Events scale was utilized for this measure. (4) Concern over a family member and alcohol/drug use: One item from the Substance Abuse Subtle Screening Inventory Adolescent (SASSI-A; Miller, 1985) was used (I have often felt bad or scared because of drinking or drug use of someone in my family). The choices for this statement are true (coded 1) versus false (coded 0).
Friendship variables.
Three measures of friendship were included: (1) Perceived Social Support From Friends (PSS-Friends; Procidano and Heller, 1983): Similar to the family support inventory (PSS-Family), the friends' support instrument consists of six items each rated on a 15 scale (with one reversed statement); the higher the score, the greater the amount of perceived friends' support. (2) Major Life Events for close friends (Andrews et al., 1993), an instrument composed of 13 of 14 items related to negative stressful events occurring within the past 6 months (e.g. death, arrests, suicide attempt) as reported by the participant. (3) Close friends and alcohol/ drug use: The remaining item (Had problems with drugs or alcohol) from the Major Life Events scale was utilized for this measure.
Adolescent alcohol use.
To assess alcohol use, two additional items from the SASSI-A (Miller, 1985) version that dealt exclusively with alcohol were utilized: (1) I have sometimes drunk too much beer or other alcoholic drink; (2) I have taken a drink in the morning to steady my nerves or to get rid of a hangover. True responses were coded 1, whereas false responses were coded 0.
Procedures
Parents/guardians and students were given written notification of the nature and purpose of the research study ~2 weeks prior to the administration of the HHSHS. Parents/guardians who did not wish their child to participate returned a self-addressed postcard. The students whose parents did not decline participation were presented with a formal consent document on the day of the administration. Students who provided their assent were administered the HHSHS in their homeroom classes by teachers who had been previously instructed on the protocol. Teachers were given an instruction sheet which the teachers read to students before the survey was distributed. In the case of slow readers, teachers assisted students in reading of the items and response choices. A very small minority of students required assistance. All of the procedures were approved by the University of Hawaii's Committee on Human Studies [CHS; i.e. Institutional Review Board (IRB)]. Based on the enrolments during those school years, ~60% of the students in the five high schools participated in this investigation.
Statistical analyses
Univariate and multiple logistic regression analyses (LRAs) were performed with the four major domains (i.e. demographic, self, family, friendship) as predictors of adolescent alcohol use. This type of analysis was conducted for all participants combined, for Hawaiians only, and then for non-Hawaiians only.
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RESULTS |
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To determine the relative contribution of risk and protective factors in the prediction of adolescent alcohol use, univariate LRA and a multiple LRA were performed for Hawaiians and non-Hawaiians combined (see Table 2). For the first SASSI item (I have sometimes drunk too much beer or other alcoholic drink), the overall rate of endorsement was 28.3% (844 of 2980). The difference between 28.8% (534 of 1854) for Hawaiians versus 27.5% (310 of 1126) for non-Hawaiians was not statistically significant.
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For the SASSI Item 2 (I have taken a drink in the morning to steady my nerves or to get rid of a hangover), the prevalence rate was much lower, as would be expected, at 2.8% (84 of 2980). The difference between 3.7% (84 of 1854) for Hawaiians versus 1.3% (15 of 1126) for non-Hawaiians was statistically significant (P < 0.0001).
The univariate LRAs revealed that a true response for SASSI Item 2 was predicted by three of the five demographic variables (Hawaiians, lower main-wage earners' education level, and lower self-reported grades) and all 11 remaining (self, family, and friendship) variables with nine of the 11 variables positively related to higher rates of alcohol use and only family support and friends' support negatively related to higher rates of alcohol use. For the multiple LRA, the overall model 2 was significant with 19.8% of the variance accounted for by the model. However, only seven of the predictor variables were significant (ethnicity, gender, self-reported grades, CES-D, family support, concern for a family member, and Major Life Events Friend), with gender not previously significant in the univariate LRA (i.e. males using alcohol at a higher rate than females). This indicated that a fair degree of overlap (correlation) existed between the variables that no longer predicted alcohol use.
To determine whether ethnic differences existed in the prediction of alcohol use by the risk and protective variables, similar LRAs were conducted for Hawaiians (Table 3) and non-Hawaiians separately (Table 4
). For the Hawaiians, SASSI Item 1 was predicted (using univariate LRAs) by 14 of 15 variables (all except friends' support; females with a higher rate than males; all other variables in the direction found for the entire sample). Gender, main-wage earners' education level, and a close friend with a drug/alcohol problem, were no longer significant when the multiple LRA was employed. For the SASSI Item 2 using univariate LRAs, self-reported grades, all four self variables, three of four family variables (family support, Major Life Events, and concern for a family member), and all three friendship variables were significant predictors (in the direction found for the entire sample). Based on the multiple LRA, only six variables were significant (males with a higher rate than females, self-reported grades, CES-D, family member with a drug/alcohol problem, concern for a family member, and Major Life Events Friend). Unexpectedly, the more a family member had a drug/alcohol problem, the less likely the student had drinks in the morning, but only when all other predictors were controlled for in the model.
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DISCUSSION |
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Additional support for a significant difference in alcohol use between Hawaiians and non-Hawaiians was provided by the SASSI Item 2. For this item, taken a drink in the morning, Hawaiians had a significantly higher rate, at 3.7%, than non-Hawaiians at 1.3%. This higher rate on the part of Hawaiians could mean many things: (1) for Hawaiians there might be less of a stigma, or greater permissibility to drink in the morning, (2) or a greater tendency to develop physiological dependence on alcohol.
The results generally supported past research findings whereby traditional risks (e.g. psychiatric symptomatology, stressful life events, poor academic grades) were significant predictors of more severe forms of alcohol use, whereas protective factors (e.g. family support) were associated with less alcohol use. The total variances accounted for (>15.0%) suggested a relatively effective model in the prediction of both SASSI items separately.
Friends' support for both Hawaiians and non-Hawaiians, and gender for non-Hawaiians were not statistically significant predictors of sometimes drunk too much. The former indicated that general peer support was neither a protective nor a risk factor, whereas the latter finding suggested that Hawaiian females may be at a higher risk for drinking too much, as compared to Hawaiian males at least as perceived by Hawaiian females and males, respectively. The variable of major stressful life events for the students exhibited one of the stronger associations for both Hawaiian and non-Hawaiian groups. This finding highlighted the possible negative environmental influences on whether adolescents felt that they were drinking too much. The results of the multiple logistic regression generally supported the association between the predictor variables and drinking too much, although some risk and protective factors predicted the same variance and thus were no longer statistically significant.
The self variables remained relatively effective predictors of the SASSI Item 2 (taken a drink in the morning) suggesting co-occurrence of internalizing (depressive, anxiety) and externalizing (aggressive) symptoms for this variable. Although social (family and friends') support and major life events for the family were important predictors for both the Hawaiian and non-Hawaiian samples, major life events for close friends, and concern for a family member and close friend due to drinking or drug use were associated with taking a drink in the morning for Hawaiians, but not for non-Hawaiians. These results may reflect partially the additional importance placed on the family, or ohana, for Hawaiians, with role-modelling, in that in a family where there is someone with an alcohol problem, whose drinking is a cause of concern, morning drinking by the problem drinker is copied by the adolescent. Werner and Smith (1992) and others have reported on the association between parental use of alcohol and child/ adolescent use. It is conceivable that genetic transmission of alcoholism might be stronger in Hawaiian, than non-Hawaiian, families. Common socio-environmental variables may also play a role. The findings based on the multiple logistic regression indicated that unique predictors remained in each domain (i.e. demographics, self, family, friends) for Hawaiians. Only the main-wage earners' education level uniquely predicted morning drinking for non-Hawaiians.
The prediction of the main-wage earners' education level proved to be interesting. For Hawaiian adolescents, the higher the earners' education, the less likely students sometimes drank too much. For non-Hawaiian adolescents, the converse was found (i.e. the higher the earners' education level, the more likely students sometimes drank too much). However, the variances accounted for were very low (i.e. <1%). Of greater importance, perhaps, was the higher variance accounted for (i.e. 3.34.3%) in the earners' education, predicting in a negative direction the non-Hawaiian students taking a drink in the morning.
The overall conclusion is that traditional risk and protective factors are associated with alcohol use for adolescents of Hawaiian and non-Hawaiian ancestry in Hawaii, although one difference between the two ethnic groups, the predictors of morning drinking, might merit further exploration. Variables related to psychiatric symptoms and major stressful life events for the student should be given ample consideration, as well as family, peer, and demographic factors, in developing and implementing prevention and treatment programmes. Further research is needed to extend these types of studies by examining the relationship between more comprehensive assessments of alcohol use and relating these measures to unique cultural variables (e.g. Hawaiian ethnic identity) in a longitudinal design to better understand risk and protective factors to enhance the efficacy of prevention and treatment programmes.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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