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Protective Factors For Alcohol Consumption Psychology Essay

Alcohol use is a major health concern, causing more than 2 million deaths each year National Council on Alcoholism and Drug Dependence. In order to combat dangerous levels of alcohol consumption, it is vital to find out why people start drinking in the first place. This dissertation aims to investigate the influence of the risk and protective factors for alcohol use among 15-16 year old students in Malta. 227 form five students from Church, Independent and State schools completed a questionnaire on alcohol use and risk and protective factors. The results illustrate that communication and emotional support from family members and friends; safety at school; bullying; as well as alcohol in public places, are particularly related with alcohol use or alcohol avoidance.

Keywords: Alcohol use, Risk and Protective Factors, Adolescents, Secondary School

Acknowledgements

I would like to thank the following persons, for without them, this dissertation would not have been possible;

Professor Carmel Cefai, my tutor, for guiding me all the way through this project, for his time, patience and whose support was greatly appreciated throughout this process,

Dr Liberato Camilleri for his insight, aid and readiness to help,

The World Health Organization and the Centre for Addiction and Mental Health for granting me permission to use their questionnaires,

All the schools that took part in the study, who took the time to meet and discuss any problems or queries,

All the participants and their guardians for their invaluable time,

Finally, I would like to thank my family and friends for their constant support, encouragement and patience.

Table of Contents

List of Figures

List of Tables

Chapter 1: Introduction

Alcohol has been a part of Maltese culture for many years, it is used in a variety of social settings; celebrations, a night out with friends, or even a glass or two of wine with a meal is acceptable. It is often regarded as a “...normal part of growing up” (Bagnall, 1991; National Institute on Alcohol Abuse and Alcoholism, 2006, p. 6). However, research has indicated that it is the most used misused and abused substance by European adolescents and adults – making it a major health concern (National Institute on Alcohol Abuse and Alcoholism, n.d.). It is accountable for around 2.5 million deaths worldwide each year (National Council on Alcoholism and Drug Dependence, n.d.).

“The problem of young drinking doesn’t take place in a vacuum, but with a backdrop of alcohol-adoring adults including parents, teachers, doctors, police... and of course, celebrities” (Sigman, 2011, p. ix). Thus; “in order to prevent the misuse of alcohol... it is necessary to have some ideas about why they are used, and in what way” (Bagnall, 1991, p. 7). Only after knowing why certain behaviours are being exhibited, can we work towards identifying the factors that can lead to or away from alcohol use, and how to reduce the risks and empower the protective factors: “Identifying adolescents at greatest risk can help stop problems before they develop, ... and innovative, comprehensive approaches to prevention” (National Institute on Alcohol Abuse and Alcoholism, 2006, para. 43). Thus it is important to focus on both the risk and protective factors in order to prevent alcohol use and misuse in adolescents and young adults (Randolph, Russell, Harker Tillman & Fincham, 2010).

Objective of the Study

Alcohol use is ingrained very deeply into our culture, thus it is important to find ways and means to keep alcohol consumption rates low, and prevent adolescents from starting experimenting with alcohol earlier on. For this reason, this study examines; the risk and protective factors that lead to and away from alcohol consumption in school-aged adolescents in Malta. Only by knowing why certain behaviour is being exhibited, can we start changing that behaviour.

Participants will be asked to complete a questionnaire enquiring about the frequency of alcohol consumption as well as the risk and protective factors in relation to the self, peers, family and other social systems.

Definition of Key Terms

The following is a list of definitions of common terms which the reader will encounter throughout this dissertation.

Binge drinking/heavy episodic drinking. “For men... drinking more than 8 units of alcohol ... for women... drinking more than 6 units of alcohol” in a short space of time (Drink Aware, 2013, para. 3)

Drunk. “...intoxicated with alcohol to the extent of losing control over normal physical and mental functions” (Fralex, 2013, para. 1).

Risk factor. “Factors associated with greater potential for... [substance] abuse…” (National Institute on Drug Abuse, 2003, p. 6).

Protective factor. “Factors… associated with reduced potential for... [substance] abuse…” (National Institute on Drug Abuse, 2003, p. 6).

Overview of the Study

The next chapter (Chapter 2) will have a look at the existing literature on alcohol use among adolescents, starting off with local demographic figures in relation to alcohol consumption. It will then review the international literature in relation to the risk and protective factors. Chapter 3 will focus on the research design and methodology used in this study, describing the process of data collection and analysis, the participants in the study as well as the research tool utilized in this quantitative study. The penultimate chapter (Chapter 4) will present the results of the study which will lead to the final chapter (Chapter 5) where the findings will be discussed, concluding the study with an examination of its implications and suggestions for future research.

Chapter 2: Literature Review

2.1. Introduction

The aim of this chapter is to review existing research and data about alcohol use among adolescents, including the local context. It will tackle some of the consequences of alcohol use before delving into the main risk and protective factors for alcohol use among young adolescents, including individual/peer relationships, family, school and community.

2.2. Developmental processes and behaviour

Adolescence is a time of change, where individuals seek to become more autonomous in their lives, by making their own decisions and loosening the grip that their parents have on their lives. In doing so, peer relationships become an influential process in adolescents’ lives and in many instances take precedence over parents’ opinions. At this time adolescents also develop a sense of “invulnerability to injury, harm and danger” (Lapsley, Aalsma, & Halpern-Felsher, 2005, p. 2), making them more liable to engage in experimentation and risky behaviours

2.2.1. Developmental needs.

Maslow spoke about a hierarchy of five levels of needs which one must fulfil in order to become self-actualized, namely; physiological, safety, love and belonging, esteem and self-actualization, but this study will focus on the latter three (Hall, Lindzey, Loehlin, & Manosevitz, 1985). He stated that people need to “feel part of a home and family, a circle of friends and neighbours... they need to feel that they belong somewhere instead of being transients or newcomers” (belongingness and love). There is also a need for respect from others, a sense of importance and appreciation; and respect from themselves: “the needs for strength, mastery, competence, self-confidence, and independence” (esteem needs) (Hall, Lindzey, Loehlin, & Manosevitz, 1985, pp. 204-205). There is a need for knowledge, “to learn, explore, discover and create to get a better understanding of the world around them” (cognitive needs) (Gautam, 2007, para. 7).

Interference in attaining the needs, for example, “when [love needs] are unsatisfied, a person will feel keenly the absence of friends... [They] will hunger for relations with people in general... and will strive with great intensity to achieve this goal. Attaining such a place will matter more than anything else in the world...” (Maslow, 1987, p. 20) and may give rise to an identity crisis. This could happen at any point in a person’s life as the needs can be re-evaluated at any point in time; “therefore we can consider the process of healthy growth to be a neverending series of free choice situation, confronting each individual at every point throughout his life” (Maslow, 1968, p. 76). However, the move toward actualization requires “good environmental conditions” including respecting and supporting ones freedom of choice and “a socialization process that fosters equality and trust between people” (Ryckman, 2008, pp. 431-432).

2.2.2. Sense of identity.

As Eric Erikson argued, adolescence is also an adjustment process;

A sense of uniqueness as a person, a desire for a meaningful role and place in society, and efforts to define self and goals lead to the development of a sense of identity. But puberty, physical growth, the necessity of leaving childhood, and uncertain values make this transition the most difficult of all, and the adolescent may become confused over who and what he or she is and wants to be (Hall, Lindzey, Loehlin, & Manosevitz, 1985, p. 79).

It is a time where adolescents begin to form a sense of self - an identity, and they become aware of their own strengths. In situations where adolescents feel unsure of themselves and their abilities, an identity crisis is set to ensue. Identity crisis is a normal phase of development especially since identity is not completely fulfilled at adolescence, it is an opportunity to learn, or if the problems are not resolved adequately, a new search for identity may arise. In their search for a new identity, adolescents may look up to new role models, be it a celebrity, a family member or even a peer group (Ryckman, 2008). Depending on whom their new idols are, adolescents may delve into risk taking behaviours, such as substance use (Boeree, 2006).

James Marcia built on Erikson’s theory of identity, focusing primarily on adolescent development. Essentially he stated that “identity structure is dynamic not static. Elements are continually being added and discarded. Over a period of time the entire gestalt may shift” (Marcia, 1980, p. 109), and “These... decisions made throughout one's life that determine "who" that person will be” (Breaux, 2009, para. 6).

2.2.3. Learning theories: reinforcement and role modelling.

Bandura’s Social learning theory builds upon the concept of role models, imitating and observing other people’s behaviour to explain why adolescents may start engaging in alcohol use (Reber & Reber, 2001);

Human behaviour as learned from the social environment...cultural and subcultural norms define whether alcohol use will be encouraged at all and, if so, in what quantities and under what conditions. These group norms are learned by observation of socializing agents, such as the drinking behaviour of adults and the presentation of alcohol use in the media. (Maisto, Carey, & Bradizza, 1999, p. 112)

Positive and negative reinforcement also comes into play (Miltenberger, 2012). For example, the more free spirited personality that may arise due to alcohol consumption serves as a positive reinforcer, while reduced shyness and “stress reduction through drinking” may serve as negative reinforcers. Ultimately, “If these stressful occasions of use become frequent enough and begin to interfere with the individual’s life, then it becomes likely that an alcohol use disorder will develop” (Maisto, Carey, & Bradizza, 1999, pp. 112-113)

2.2.4. An integrative, biopsychosocial perspective.

It is important to take the biospychosocial model into account, as it encompasses the “biological, psychological, and social factors ... [as] important determinants of health and illness” (Taylor, 2012, p. 6). The biological aspects include, but are not limited to, genetic factors including metabolic rates, individual factors, such as the person’s physical health, alcohol expectancies, and temperament; the psychological factors include personality characteristics, self-efficacy and locus of control; and the social factors include the media, family, peers and culture (Schulte, Rame & Brown, 2009; Kumpfer, Trunnell & Whiteside, 2012);

 For example, family environmental factors, such as parenting style, family stressors, and family resources can have an "interactive" effect on the physiological and temperament characteristics in the child. ... These proposed bi-directional influences have been substantiated in relational studies of children and their parents (Lewis and Lee-Painter, 1974). (Kumpfer, Trunnel, & Whiteside, 2012, para. 33)

Thus one needs to take all three aspects into account, as the interaction of all three aspects happens through systems theory, where “real systems are open to, and interact with, their environments, and that they can acquire qualitatively new properties through emergence, resulting in continual evolution” (Heykighen & Joslyn, 1992, para 3). Hence, “...change in any one level will effect change in all the other levels” (Taylor, 2012, p. 7).

2.3. Alcohol use among Teenagers

In a study amongst 38 countries in Europe and North America, Malta has one of the highest alcohol consumption rates amongst 15 year olds: 39% of girls and 51% of boys reported to drink alcohol on a weekly basis (Health Behaviour in School-aged Children, 2004, p. 75). The fourth international report on the European School Survey Project on Alcohol and other Drugs (ESPAD) found similar results. The survey, which was held in 35 European countries among 15-16 year olds, reported that Malta scored an alcohol consumption rate that was slightly higher than the ESPAD average. It also revealed that 62% of boys and 52% of girls in Malta reported to have consumed 5 or more drinks in a row the preceding 30 days, giving Malta the 3rd highest binge drinking score (Hibel, Guttormsson, Ahlstrӧm, Bjarnason, Kokkevi & Kraus, 2012).

The 2011 ESPAD Report stated that the amount of alcohol used during the preceding 30 days in Malta has indeed decreased to 68% (70% of boys and 66% of girls) however; the heavy episodic drinking rate in the previous 30 days has remained the same at 56%. Both of these percentages are still above the ESPAD average of 57% (boys) and 39% (girls) respectively (Hibel, et al., 2012), giving Malta the 8th highest score. 20% (21% of boys and 18% of girls) of Maltese students also reported being drunk the previous 30 days, while 56% reported to having 5 or more drinks on the same occasion during the past 30 days.

2.4. Consequences of Alcohol Use

“Alcohol is our favourite drug. ... [However, it] causes much more harm than illegal drugs… it is addictive, and is the cause of many hospital admissions for physical illnesses and accidents” (The Royal College of Psychiatrists, 2008, para. 2). It has also been related to other adverse reactions, such as poor judgement, cancer, muscle damage which can also result in liver and/or kidney failure, brain damage, and even death (Mayo Foundation for Medical Education and Research, 2006).

Numerous adverse reactions to alcohol use have been found, typically when related to brain functioning;

Heavy drinking has been shown to affect the neuropsychological performance (e.g., memory functions) of young people and may impair the growth and integrity of certain brain structures. Furthermore, alcohol consumption during adolescence may alter measures of brain functioning, such as blood flow in certain brain regions and electrical brain activities… [suggesting] that alcohol exposure during adolescence and young adulthood can cause subtle yet consequential damage (Tapert, Caldwell, & Burke, 2006, p. 1).

Other behaviour problems may also arise due to alcohol consumption, such as violent behaviour, causing injuries to self and others, additional substance use and criminal behaviour (Wagenaar, Toomey, & Lenk, 2005; Hollin, 2006). Impaired judgement can also result from alcohol use, as alcohol can reduce inhibitions, which can lead adolescents to engage in risky behaviour such as poor decision making and sexual activity (National Institute for Alcohol Abuse and Alcoholism, 2012). Early onset of alcohol consumption has been linked with later alcohol use and exacerbation of other psychical and mental illnesses presently and later on in life (National Institute for Alcohol Abuse and Alcoholism, 2012).

2.5. Risk and Protective Factors

2.5.1. Risk Factors are defined as “...any influences that increase the probability of onset, digression to a more serious rate, or maintenance of a problem condition” (Fraser, 1997, pp. 10-11). They can be genetic or even environmental, and they increase the probability of negative outcomes, such as alcohol use and misuse (Kurlychek, Krohn, Dong, Penly Hall, & Lizotte, 2011).

2.5.2. Protective Factors are those aspects and conditions which when present increase the health and well-being of the person while reducing or even removing the effect of the risk factors. As a result of protective and resilient factors, many adolescent who are exposed to risk factors still manage to succeed in their everyday life and maintain healthy relationships (Fraser, 1997). Protective factors reduce the impact of the risk factors and in turn, reduce the likelihood of later delinquency (Kurlychek, Krohn, Dong, Penly Hall, & Lizotte, 2011).

Hawkins and Catalano (Social Development Division, 2003) found that there are risk and protective factors which can sit within the individual and their context, namely:

Individual and peer factors

Family factors

School

Community

2.5.3. Individual and Peer Factors. Adolescence is a time of change in physical development, relationships, emotions and lifestyle, which have been seen to increase independence (National Institute on Alcohol Abuse and Alcoholism, 2006). In this time, adolescents seek independence from parents, and in doing so, their relationship with their peers changes. More time is spent with their peers and “peer relationships typically become the primary social context that influences social development” (as cited in Rubin, Bukowski, & Parker, 2006; Trucco, Colder, Bowker, & Wieczorek, 2010, p. 527).

The NIAAA went on to say that:

As children move from adolescence to young adulthood, they encounter dramatic physical, emotional, and lifestyle changes. Developmental transitions, such as puberty and increasing independence, have been associated with alcohol use. So in a sense, just being an adolescent may be a key risk factor not only for starting to drink but also for drinking dangerously (National Institute on Alcohol Abuse and Alcoholism, 2006, pp. 1, para. 6).

Self-efficacy is an important determinant of alcohol use. It is what Bandura labelled “an individual’s sense of their abilities, of their capacity to deal with the particular sets of conditions that life puts before them” (Reber & Reber, 2001, p. 661). Ian Newman, Duane Shell, Qu Ming, Xue Jianping and Michelle Maas (2006), who conducted a study regarding adolescent alcohol use among 1020 students, stated that:

If two people have essentially the same knowledge and the same expectancies and equal desire to not participate in a behaviour they are being pressured to carry out, the one with the higher level of self-efficacy (confidence) to resist the pressure will be more likely to resist the pressure than the person with the lower level of self-efficacy. (Newman, Shell, Ming, Jianping, & Maas, 2006)

Individuals with high self-esteem are also less likely to give into social and peer pressure that conflict with their own personal beliefs (Bagnall, 1991). Having a positive orientation and good decision-making skills also helps protect adolescents from engaging in alcohol use. Epstein, Zhou, Bang and Botvin, (2007) stated that “...using sound decision-making skills as learned in anti-alcohol programs reduces the odds of both current and future drinking and can moderate the relationship between risk factors and current use” (as cited in Randolph, Russell, Karker Tillman, & Fincham, 2009, p. 550).

Whilst the risk and protective factors are very similar, they often differ in their effect. For example, students who view themselves with a low expectation of success have a greater risk for alcohol use than students who have a positive self-regard. Also, students who have a general sense of hopelessness about life are more likely to engage in alcohol consumption than students who have a positive outlook on life. Consumption of alcohol at an early age is yet another risk factor for continued alcohol use in contrast to late onset consumption (Social Development Division, 2003).

“‘Birds of a feather flock together’ ... [adolescents] tend to act like their peers. … [Thus] teens that do not…use alcohol don’t want to be around those who do-and vice versa” (Donahue & Hedrick, 2011, p. 26). Another instance where risk and protective factors differ in domain is whereas peer pressure is seen as a risk factor, positive peer support is a very strong protective factor, “...the association between an individual’s alcohol use and that of his or her peers has been assumed to reflect the action of modelling processes, as well as direct differential reinforcement, on the individual’s drinking” (Maisto, Carey, & Bradizza, 1999, p. 141), reflecting a proportional correlation between adolescent and peer alcohol use.

A teen that has friends who use... alcohol... increases the odds that he or she will... [do so] too. Kids, especially those who feel they don’t fit in ... will seek out those who do not require much from them. Substance users – at least at the start – do not require anything of their friends. They will be your friends whether you drink ... or not (Donahue & Hedrick, 2011, pp. 26-27).

Davies and Stacey (1972) found that although there were many peer factors that influence drinking habits, peer pressure and peer approval seemed to be the most significant factor (as cited in Fraser, 1997; Pedersen & Kolstad, 1999; Brӓnstӧrm, Sjӧstrӧm & Andréasson, 2007; Rnadolph, Russell, Karker Tillman & Fincham, 2009). Whereas Cloninger, Sigvardsson and Bohman (1988) found that a sensation-seeking personality is a strong predictor for alcohol use (as cited in Fraser, 1997).

2.5.4. Family factors. Parental attitudes towards drinking, especially that of the father towards the son, was found to be the most important influencing factor that they had on their children (O’Connor, 1978; Rosie et al., as cited in National Institute on Alcohol Abuse and Alcoholism, 2006). Adolescents who claim to never drink any alcoholic beverages seem to be influenced by their parents who also abstained from alcohol use. Likewise, moderate drinkers came from moderate drinking families. However, heavy drinkers seemed to either come from families where both parents were heavy drinkers, or where both parents are abstainers (Gordon & McAlister, 1982, as cited in Bagnall 1991). On the other hand, parental disapproval of adolescent drinking, general discipline, greater parental monitoring, good parent-child “relationship quality, parental support and general communication” were found to be associated with lower levels of alcohol use later in life (Siobhan, Jorm, & Lubman, 2010).

Siobhan, Jorm and Lubman (2010) also found an association between early initiation to drinking and parental modelling, provision of alcohol and greater parental monitoring. Alcohol-specific communication was not found to be associated with early alcohol initiation. However, general communication seemed to delay early initiation to alcohol, as did good parent-child relationship quality and parental involvement. They also found that parental modelling and provision of alcohol seemed to increase the levels of alcohol consumption later on in life (Siobhan, Jorm, & Lubman, 2010). As Fraser (1997) noted, “poor parenting practices, such as inadequate supervision of children, inconsistent responses to children’s behaviour, and constant nagging, may increase the risk that a child will be noncompliant in home, school and other settings” (p. 13).

Having a good relationship with at least one parent can significantly reduce the probability of engaging in risky behaviour (Randolph, Russell, Karker Tillman, & Fincham, 2009). In fact, Werner (1994), found that “children who abstained from drug use during adolescence and early adulthood were found to have had positive parent-child relationships in early childhood and caring relationships with siblings and grandparents.” He also went on to say that “children abstaining from alcohol and other drugs also received social support and frequent counsel from teachers, ministers and neighbours” (as cited in Fraser 1997, pp. 124-125).

Adolescents whose parents have a high educational achievement were found to engage in alcohol consumption behaviours less frequently than adolescents whose parents had a lower educational level of achievement (Thorlindsson, Bjarnason, & Sigfusdottir, 2007).

The home environment, “including poor inconsistent parenting skills,” “poor relationships”, “low bonding” and “no nurturing” may all serve as risk factors (Fraser, 1997; Social Development Division, 2003). On the other hand, a “secure stable family,” encompassing “strong family norms” and “strong bonds between family members” (for example, having “supportive caring parents”) serve as protective factors (Social Development Division, 2003). As we can see, the risk and protective factors are in the same domain, what makes them a risk or protective factor is the way in which each aspect is used.

2.5.5. Community and Social Factors. “Neighbourhoods are... important ecological contexts in which adolescents’ lived experiences are embedded, particularly given their constrained geographic mobility” (Tanner-Smith, 2012, p. 624) thus making it a significant influence on the adolescents’ behaviour. A sense of belonging to a community; for example, forming part of a religious institution, and connecting with other adults in the community were found to be long term protective factors (Sinha, Cnaan & Gelles, 2006 as cited in Randolph, Russell, Harker Tillman & Fincham, 2010; Voisin et al., 2005, as cited in Randolph, Russell, Harker Tillman & Fincham, 2010; Thorlidsson, Bjarnason & Sigfusdottir, 2007).

Most community factors have previously been seen as risk factors, however, Maimon and Browning (2010) focused on the collective efficacy [1] as a protective factor. They found that, “...collective efficacy has both a direct effect on reducing violent outcomes and an indirect effect through its role in reducing unstructured socializing of peer groups” (as cited in Kurylchek et al., 2011, p. 88).

“...Collective socialization, or the ability for neighbourhoods to assemble necessary levels of social cohesion and support that provides a positive context for adolescents” was found to be a very strong protective factor. Community supportiveness was not only linked to a delay in first use of alcohol, but also to less alcohol use in the preceding month, and “adolescent perceptions of a supportive community, containing adults interested in both their activities and well-being, appeared to be a strong protective factor...” (Jencks & Meyer, 1990, as cited in De Haan, Boljevac & Schaefer, 2010, p. 631-644). Thus, “access to support services, community networking, healthy leisure activities, strong bonds with pro-social institutions and a strong cultural identity” could shield the person from engaging in alcohol use (Social Development Division, 2003).

Various factors in the community can influence a person’s alcohol consumption behaviour, including; violence in the community, substance availability, and lack of law enforcement (Social Development Division, 2003). Tanner-Smith (2012) goes on to state that “...high exposure to drugs and less informal social control may amplify ... substance use...” thus living in an unsafe community can serve as a very strong risk factor (Branstrom, Sjostrom, & Andreasson, 2007).

Joksch (1988) found that having laws which seem to favour alcohol use (such as low taxes on alcoholic beverages and having a low legal drinking age) are likely to increase alcohol use in adolescence. In fact, he found that lowering the legal drinking age increased underage drinking. On the other hand, Johnston (1991), found that having explicit laws curbing alcohol use in adolescence is linked with lower frequency of alcohol use in adolescents (as cited in Fraser, 1997).

The media and celebrities are strong influencing factors on alcohol use in adolescence. In fact, the National Institute on Alcohol Abuse and Alcoholism (2006) has pointed out that the media is a very strong influencing factor, as alcohol is promoted through every source; television, radio, internet, news, and even advertisements. They also found that students who found the advertisements pleasing were more likely to think of drinking as something positive and would want to buy those products. However, this research is inconclusive on whether it leads to underage drinking (National Institute on Alcohol Abuse and Alcoholism, 2006).

Research conducted by the UK’s Economic and Social Research Council (2006), found “that celebrities renowned for their party lifestyles... were repeatedly cited as evidence that drinking to excess could be attractive and posed few risks.” They also found that “Electronic media, including social networking sites, were seen to reinforce the connection between fun and heavy drinking... because many young people used them to exchange images of alcohol-fuelled exploits” (as cited in Sigman, 2011, pp. 32-33).

2.5.6. School factors. Adolescents spend the majority of their week at school, thus making it a very important influential factor over the person’s life as “...adolescents are exposed to positive and negative social interactions during the school day, both of which are likely have a strong influence on subsequent adjustment and behaviour” (Wormington, Anderson, Tomlinson, & Brown, 2012, p. 2; Sussman & Stacy, 1994).

Resnick et al., (1997), found a negative relationship between commitment to school and alcohol use; the more committed students are to school, the less they engage in alcohol consumption behaviours, which also resulted in lower levels of alcohol use later on in life (as cited in Mrug & Windle, 2009). Non-drinkers showed greater overall satisfaction at school (Conner, Mason, & Mennis, 2012) and “...students who performed well in the classroom... were less likely to report binge drinking...” (Wall, BaileyShea, & McIntosh, 2012, p. 33).

The 2009 National Youth Risk and Behaviour Survey found “...a negative association between alcohol ... use and academic achievement; ... students with higher grades are less likely to engage in alcohol ... use behaviors than their classmates with lower grades, and students who do not engage in alcohol ... use behaviors receive higher grades than their classmates who do engage in alcohol use behaviors.” (Center for Disease Control and Prevention, n.d., para. 1).

Bergen, Martin, Roeger and Allison (2005) found a relationship between “actual or perceived decline in self-esteem ... perceptions of academic failure” and substance use (Bergen, Martin, Roeger, & Allison, 2005, pp. 1568-1569). However, deciphering between which causes which is still unclear. Nevertheless, “... low academic self-esteem may be a useful means of identifying adolescents at risk of future substance misuse, in addition to those engaging in antisocial behaviour and early substance use” (Bergen, Martin, Roeger, & Allison, 2005, p. 1569)

The number of supervised activities was also associated with less alcohol use; “...the level of monitoring in each school is associated with less alcohol use” (Thorlindsson, Bjarnason, & Sigfusdottir, 2007, p. 72). However, institution size also affected drinking behaviours; “with higher drinking rates at institutions with the highest... and lowest enrolments...” meaning that the largest and smallest schools reported higher drinking rates than medium sized schools (Wall, BaileyShea, & McIntosh, 2012, p. 33).

Conner, Mason and Mennis (2012) underline the importance of taking subjective experience at school into account when assessing alcohol use. Students reporting greater overall satisfaction towards school were found to be abstainers, or at least, engage in alcohol less frequently. Views towards the institution and staff has also been found to be related to substance use; “Greater dissatisfaction with school and teachers is associated with greater usage…” (Conner, Mason, & Mennis, 2012, p. 681). Surprisingly, Mrug and Windle (2009) found that “higher levels of school connectedness did not seem to protect preadolescents from negative peer influence on subsequent externalizing behaviour” (Mrug & Windle, 2009, p. 535). This contrasts with other studies in the area such as that by Resnick et al (1997).

Peleg-Oren et al., (2010) found an association between alcohol use and bullying behaviour, such that individuals involved in bullying behaviour were seen to have engaged in alcohol use more frequently, and students who were not involved in bullying behaviours reported drinking alcoholic beverages less often (Peleg-Oren, Cardenas, Comerford, & Galea, 2010). Consequently, “highly victimized boys were most at risk for early onset substance use...” (Wormington, Anderson, Tomlinson, & Brown, 2012, p. 15).

2.6. Summary and Conclusion

This chapter gave an overview of the literature pertaining to the main risk and protective factors that can lead to alcohol use in adolescence, namely individual and peer factors, family influences, community and social factors, finishing off with school factors. An amalgamation of the different factors may lead to stronger predictions of behaviour. The subsequent chapter will deal with the methodological aspects applied in this dissertation.

Chapter 3: Methodology

3.1. Introduction

This chapter gives an overview of the methodological aspects of this research study. It will present the aims of the study, followed by giving an overview of the research tool used, the pilot study, the steps taken in data collection, some information about how participants were chosen and it will finish off with how the analysis was carried out.

3.2. Objective of the Study and Rationale of Design

The aim of this study is to explore the risk and protective factors in alcohol use among Maltese adolescents, and how these vary by gender and type of school. For the purpose of this study, adolescents aged 15 and 16 were chosen and studied through a self-administered questionnaire. More specifically, this study sought to address the following;

Hypothesis 1: Adolescent alcohol consumption is related to the way they view and feel about themselves and their confidence in their own abilities.

Hypothesis 2: Adolescent alcohol consumption is related to the adolescent’s family relationships, family dynamics and psychological processes within the family.

Hypothesis 3: Adolescent alcohol consumption is related to the type of relationships that adolescents have with peers

Hypothesis 4: Adolescent alcohol consumption is related to community factors, such as norms, availability and violence in said community.

Hypothesis 5: Adolescent alcohol consumption is related to adolescents’ relationships and engagement at school

A quantitative research approach was chosen to investigate the research question, as it provides an empirical analysis of adolescents’ behaviour, opinions and attitudes in relation to alcohol use. Although it has its drawbacks since grouping data together removes the significance of individual differences, and it may oversimplify human nature, it also has its benefits as claims and predictions can be made about the situation and projected onto the population as information may be gathered from a representative sample of the population (Nykiel, 2007; Landridge & Hagger-Johnson, 2009).

3.3. Participants and Procedure

3.3.1. School and student selection.

Schools: An opportunistic sampling method was utilized to choose the schools where the questionnaire would be administered. Three lists of schools were shortlisted; Church, State and Independent schools. The schools on the list were contacted until two Church schools (one girls’ and one boys’), two State schools (one girls’ and one boys’) and a Mixed Independent school were found and agreed to participate.

Students: All the students in Form 5 in the selected schools were asked to participate; however, being a voluntary process, they had the choice of whether they wished to participate or not.

3.3.2. Student characteristics.

573 form 5 students were asked to participate in the study; however 227 adolescents completed the questionnaire; 53 boys and 174 girls, yielding a response rate of 39.6%. My sample consisted of 36.56% (=83; girls [=78] and boys [=5]) of adolescents from the state schools, 39.65% (=90; girls [=71] and boys [=19) of adolescents from the church schools and 23.79% (=54; girls [=25] and boys [=29]) of adolescents from the independent school.

3.3.2. Ethical issues.

Schools: In the case of State schools, permission was sought from the Directorate for Quality and Standards in Education, the head of the college and the head of schools. In the case of Church schools, permission was obtained from the Secretariat for Catholic Education and the head of the school. In the case of the Independent school, permission was sought from the head of the school. Permission was also approved by the Faculty Research Ethics (F.R.E.C.) board as well as the University Research Ethics (U.R.E.C.) board.

The head of the schools were provided with a letter of information (Appendix F) about the nature of this study, as well as a consent form (Appendix G), and they were also allowed to review the questionnaire and any other documents that would be passed on to the students.

Students: Each student was provided with an information letter and a consent form for themselves as well as for their guardian to sign (Appendix B to E). It was made clear to everyone involved that participation was voluntary and that subjects may withdraw from the study at any time without needing to provide a reason for doing so.

3.4. Instrumentation

The questionnaire used in the study was adapted from the Health Behaviour in School-aged Children (HSBC) survey (WHO, 2008) as well as the Centre for Addiction and Mental Health (CAMH) study (2011). The questionnaire was self-administered and completely anonymous, made up of 28 questions with sub-sections that were split up into five sections, consisting of a mixture of a Likert scale (1=strongly disagree, 5=strongly agree) and check boxes.

The first section dealt with background information of the student; age, type of school attended and gender. Section two dealt with their alcohol consumption. The third section concerned their family and friends; namely their relationships and the alcohol use of family members and friends. It also dealt with their community life, with questions about how easy it is for them to get hold of alcohol in their community. The fourth section dealt with school issues; how they felt about school, how they perform at school, along with their general feelings about school. The fifth and final section asked questions regarding how the participants perceived and felt about themselves.

3.4.1. Piloting

A test-retest pilot questionnaire was administered to a group of 26 form 4 students, 10 of whom successfully completed the questionnaire. The subjects were given the questionnaire for the first time at the end of October 2012 and a second time in the beginning of November 2012. The results yielded a Cronbach’s Alpha of 0.891. The Cronbach’s Alpha for the 74 items range between 0.5 to 1, indicating weak to excellent test-retest reliability, however more than 50% of them lying between the ranges of 0.8 and 1 (which indicates a good to excellent test-retest reliability). Less than 10 questions yielded a Cronbach’s Alpha of less than 0.6, and thus, those questions were adapted or removed.

Following the feedback from the test-retest analysis, the questionnaire was translated into Maltese by a group of two people together, and then retranslated by another group of three persons. A number of questions were adapted following this process. After this, a group of 10 students answered the questionnaire in English, and a week later they answered the questionnaire in Maltese. This resulted in an average Cronbach’s Alpha of 0.864, which indicates good test-retest reliability (the results raged between 0.75 and 1, which indicates an acceptable to excellent reliability), though one must keep in mind that this was based only on 10 participants

The students were also asked to fill in a feedback sheet which asked about the time it took them to fill in the questionnaire, whether there was something they felt was missing, if they objected to answering any questions and their general feelings about the questionnaire.  

With all this information in hand, it was brought to my attention that some things needed to be changed, and so ambiguous and incomprehensible questions were either edited or removed. Thus one question was rephrased in order to remove uncertainty and to elicit the accurate information required, and a further two questions were removed.

3.5. Administration of the Questionnaire

3.5.1. School

The head or assistant head of each school was provided with packages intended for the students and their guardians. The packets included the questionnaire (Appendix A), a letter of information for the students and their guardians, as well as a consent form for both the student and parent to sign. All documents were written in both English and Maltese. The head or assistant head of the schools helped in the distribution of the questionnaire, between November 2012 and February 2013, to all the students in form 5.

3.5.2. Students

The school distributed the packet containing the letter of information, consent form and questionnaire to the students so that themselves and their guardians could make an informed decision on whether to participate or not. Moreover, it was made explicitly clear that participation was strictly voluntary and they could quit at any time. This was written not only on the letter of information, and on the consent form but also on the front page of the questionnaire.

Subjects were asked to place the filled in questionnaire in the envelope and seal it and then place the sealed envelope in the collection box at the school. They were also instructed to place the signed consent form in another collection box at the school. The questionnaire collection box was sealed leaving a slit at the top so that students could place the documents inside, and thus ensure confidentiality. I personally collected both collection boxes.

3.6. Analysis

The data collected was analyzed using IBM SPSS Statistics version 21, by means of statistical techniques such as Chi-square and one way ANOVA. A 95% level of significance was adopted for all tests, meaning that a p-value of less than 0.05 would lead to the null hypothesis being rejected, as it would not be statistically significant and the association could be due to chance (Clarke & Cooke, 1998). There is a maximum margin of error of 7.45%, meaning that if the results were projected onto the population, they may vary by plus or minus 7.45% (Mendenhall, Beaver, & Beaver, 2013).

3.7. Conclusion

This chapter gave an overview of the methodological aspects considered in this dissertation. The subsequent chapter will deal with the analysis of the results obtained from the questionnaire, by testing the aforementioned hypotheses.


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