Parenting style, distress, and problematic alcohol use in Bhutan

Abstract Background Bhutan is a small landlocked country located between India and China that is largely rural and Buddhist. As the nation develops and adopts more Western practices, the nature of the relationship between its young people and alcohol is developing as well. Objectives The present study examines how problematic alcohol use relates to parenting styles and distress in a sample of predominantly tertiary students. Methods For this study, 245 young adults completed self-report measures of parenting style, distress, and alcohol-related problems. Results Strong correlations were found indicating that more dysfunctional parenting styles were associated with greater distress and problematic alcohol use. Further analyses to evaluate the relationship between parenting styles and alcohol use found no role for moderation but a significant mediation which indicated that more dysfunctional parenting styles were associated with greater distress which in turn was associated with greater problematic alcohol use. Conclusions These findings replicate those found in Western countries and imply that the same vulnerabilities to problematic alcohol use are also present in Bhutan.


PUBLIC INTEREST STATEMENT
Bhutan, a small country located between India and China, is praised for measuring their nation's Gross National Happiness alongside other economic aspects. As such, Bhutan is often regarded as one of the world's happiest countries. However, Bhutan also has a high prevalence of alcohol consumption. In the current study, we investigated how problematic alcohol use related to parenting style and distress factors in a sample of predominantly tertiary students. The results revealed strong relationships between dysfunctional parenting styles and greater distress and problematic alcohol use. This study suggests that individuals in Bhutan are susceptible to the same vulnerabilities to problematic alcohol use as people in Western countries. & Salamoun, 2007;Patrick & Schulenberg, 2014). However, the prevalence and patterns of alcohol consumption in tertiary students from low-income, non-Western countries such as Bhutan have not been considered previously. Bhutan has never been colonised by a Western nation (Techakesari et al., 2015), and despite the adoption of many of the technological advances common in Western countries, Bhutan has not abandoned its traditional lifestyles in regard to religion, diet, and gender work roles.
A recent review of the prevalence, patterns, and predictors of alcohol consumption in a rural community in Bhutan (Subady, Assanangkornchai, & Chongsuvivatwong, 2013) found that the overall prevalence of alcohol consumption (at least one standard drink in the past year) was 38.5%. In addition, 56.6% of families included at least one drinker, and of those drinking, 23.1% drank alcohol at high intensity. In Bhutan, there is a high prevalence of home-made alcohol, particularly spirits. These factors may contribute to Bhutan having one of the highest rates of hospitalisation for liver disease among South-East Asian countries (Kypri, Dorji, & Dalton, 2017;WHO, 2014). Given this background, the relevance of parental influence on drinking rates in young Bhutanese adults may provide information relevant to intervention approaches and government policy initiatives.

Parenting style
The relationship between parental style and consumption of alcohol in Western countries has received considerable attention over the years (Čablová, Pazderková, & Miovský, 2014;Ryan, Jorm, & Lubman, 2010;Sher, Grekin, & Williams, 2005) but has not always been consistent. A systematic review of longitudinal studies by Ryan et al. (2010) found that several aspects of parental behaviour were linked with age of initiation of alcohol use and later drinking levels. In particular, greater quality of the parent-child relationship (warmth, bonding, affection) and greater parental monitoring (parent's knowledge of their child's activities and whereabouts) were significantly predictive of later age of initiation and lower levels of later drinking. More recently, Abar (2012) examined the influence of parental practices on college student alcohol use using latent profile analysis and identified four parental profiles: high quality, high monitoring, anti-alcohol, and proalcohol. Although all measures of student alcohol consumption were strikingly higher in the proalcohol parental profile, there was little difference amongst the other three profiles, indicating a complex mix of risks and protections within each profile that result in similar outcomes. Abar (2012) identified the quality of the parent-teen relationship as potentially the most important factor in limiting risk for alcohol misuse. By establishing trust, displaying support, and being accessible to their teens, (along with not modelling alcohol use), parents can instil a level of protection against the other influences and pressures to engage in excessive drinking.
The review by Čablová et al. (2014) focused on the use of alcohol by children and adolescents and found evidence of a connection between various parenting styles and alcohol use but that these connections varied with the age of the child, with gender, and with cultural values. In particular, cultural differences in parenting styles and their relation to alcohol use, and problem behaviours more generally, are becoming more apparent. As an example, Garcia and Gracia (2009), using a large sample of Spanish families, examined the relationships between four parenting styles (authoritative, authoritarian, indulgent, neglectful) and several outcome measures, including measures of self-esteem, psychosocial adjustment, personal competence, and problem behaviours (e.g. school misconduct, delinquency, drug use). They found that on most measures, both the indulgent and authoritarian styles were associated with better outcomes. This result contrasts with many previous studies from Western, individualist countries that have shown that authoritative parenting styles were almost always associated with better outcomes (Burk et al., 2011). Other findings from different cultures, such as German high school students (anxiety, coping, depersonalisation; Wolfradt, Hempel, & Miles, 2003), Korean-American adolescents (academic achievement; Kim & Rohner, 2002), Brazilian adolescents (self-esteem; Martínez, García, & Yubero, 2007), and Chinese-American adolescents (school performance; Chao, 2001) have also identified one of the other parenting styles (authoritarian or indulgent) as being associated with more optimum outcomes for these cultures or subcultures.
Hence, the present study sought to evaluate the nature of the relationships between parenting styles and alcohol use in young tertiary students from Bhutan. However, the relation between these two factors is likely to be influenced by personal variables such as self-esteem, well-being, social support, or distress. The present study therefore investigated the influence of personal distress factors and how these alter the relationship between parental style and problematic alcohol use.

Distress factors
Young adults studying at tertiary institutions may experience a degree of distress arising from the strains of homesickness, culture shock, working while studying, and various relationship complications (Dyrbye, Thomas, & Shanafelt, 2005;Fong & Loi, 2016). In addition, academic and familial pressure to succeed may contribute even further to the degree of distress experienced by tertiary students (Ross, Niebling, & Heckert, 1999). In typically more collectivist cultures, these pressures to succeed could be expected to be significant (Furry & Sy, 2015).
Distress is usually defined as resulting when an individual perceives that a stressor exceeds their coping ability (Cohen, Kessler, & Gordon, 1995). Distress conditions manifest as elevated levels of depression, anxiety, stress, burnout, and hopelessness and have been associated with greater and problematic use of substances such as alcohol, an increased risk of suicide and interpersonal conflict, impaired academic performance, and poor health (Dyrbye et al., 2005). The relationship between these distress conditions and alcohol use in young adults is well-established in Western societies (Gonzalez & Skewes, 2013;Jalilian et al., 2014;Kuntsche, Knibbe, Gmel, & Engels, 2005;Yu et al., 2006). In particular, different psychological motives for consuming alcohol have different outcomes in terms of quantity of alcohol consumed and problematic consequences. For example, drinking for social motives tends to be associated with light, infrequent, non-problematic alcohol consumption, while drinking for coping motives tends to be associated with heavier, more problematic alcohol use (Cooper, 1994;Cox & Klinger, 1988;Grant, Stewart, O'Connor, Blackwell, & Conrod, 2007). Work by Grant et al. (2007) found that splitting the coping motive into copingdepression and coping-anxiety better explained their data, but both constructs were significantly positively predictive of alcohol-related problems and that drinking alcohol to cope with depression was most significantly related to problematic outcomes.
Parental attachment dimensions have also been found to be differentially associated with alcohol use by young adults. Kassel, Wardle, and Roberts (2007), for example, found that alcohol use related to stress or negative affect was significantly predicted from an anxious adult attachment style. McNally, Palfai, Levine, and Moore (2003) argued that early caregiver interactions provide a basis for how a child learns to regulate feelings of security and anxiety and that these early experiences shape adult schemas of emotion regulation. These authors found that the use of alcohol to cope with negative affect was related to quality of attachment through negative self-views.
Hence the relationship between parents and their children is likely to be a significant factor in the formation of self-views and the child's consequent regulation of feelings of distress. Given that the experience of distress is likely to be exacerbated by entering tertiary study, the present study sought to determine the nature of these relations in a sample of Bhutanese university students.

Aims
The present study was focussed on determining the nature of the relationships between parenting styles and alcohol use in Bhutanese tertiary students. In addition, the role of distress, captured with depression, anxiety, stress, and hopelessness, was explored in predicting alcohol use.
Following Western-based findings, we expected dysfunctional parenting to be associated with greater distress and more problematic alcohol use. Distress may moderate or mediate the relationship between parental style and risky alcohol use.

Participants
A total of 325 individuals volunteered to participate in the study. Participants were recruited from Paro College, a constituent college of the Royal University of Bhutan that focuses on teacher training and includes approximately 1500 male and female students who predominantly live in separate accommodation. Some individuals were recruited from Alcoholics Anonymous and Narcotics Anonymous as a source of participants with high alcohol use. There are no restrictions on alcohol use in Bhutan or the university, nor are there religious restrictions. English is mandatorily taught to students in Bhutan from a very young age and thus all tertiary students are competent in the language. Complete data was obtained from 93 females and 152 males aged 19 to 61 years (M = 24.81, SD = 6.51). Table 1 provides further participant demographics.

Measures
The online survey battery consisted of 85 questions including demographic items.

Parenting
The 30-item Measure of Parental Style (MOPS; Parker et al., 1997) measures perceived parenting styles using three subscales: (1) indifference (e.g. "Uncaring of me"); (2) abusive (e.g. "Physically violent or abusive of me"); and (3) over-control (e.g. "Sought to make me feel guilty"). Responses are scored on a 4-point scale from 0 (not true at all) to 3 (extremely true). The scores for each of the three subscales were averaged to give mean subscale scores ranging from 0 to 3 with a higher score indicating a higher use of that parental style. The MOPS demonstrates excellent reliability and convergent validity against the Parental Bonding Instrument (Parker et al., 1997). Cronbach's alphas for indifference, abuse, over control, and the total were good in the current sample: 0.95, 0.92, 0.75, and 0.92, respectively.

Distress
Distress was measured using a combination of the 21-item Depression, Anxiety and Stress Scale (DASS-21;Lovibond & Lovibond, 1995) and the 20-item Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The three subscales of the DASS can be used as a measure of general psychological distress (Crawford, Cayley, Lovibond, Wilson, & Hartley, 2011). Furthermore, the DASS-21 demonstrates high convergent validity against other measures of anxiety and depression in non-clinical populations (Crawford & Henry, 2003). Responses on the DASS items are scored on a 4-point scale from 0 (never) to 3 (almost always).
The 20-item BHS (Beck & Steer, 1988) is a self-report measure of hopelessness which primarily assesses negative expectations about the future. Higher scores indicate a more intense level of hopelessness. Scored with a yes/no format, nine items are keyed negatively and 11 positively. The mean scores range from 0 (normal) to 1 (extremely severe).
Z scores for the three DASS subscales and BHS total score were combined into an overall distress measure. Distress had an alpha value of 0.90 for the current sample.

Harmful drinking
The 6-item Rapid Alcohol Problem Screen (Cherpitel, 2002) is a yes/no screening instrument that assesses alcohol dependence and misuse and is reported to have high specificity (92%) and sensitivity (87%) for classifying individuals meeting the DSM-IV diagnostic criteria for harmful drinking (Cherpitel & Bazargan, 2003). A yes answer is scored 1 giving a range of mean scores from 0 to 1 with a higher score indicative of greater alcohol problems. Example items include "During the last year have you had a feeling of guilt or remorse after drinking?" and "During the last year has a friend or a family member ever told you about things you said or did while you were drinking that you could not remember?" The last two questions ask about quantity and frequency of alcohol consumption ("During the last year do you drink as often as once a month?" and "During the last year have you had five or more drinks on at least one occasion?"). The Cronbach's alpha for the current sample was good (α = 0.80).

Procedure
Qualtrics software (Provo, UT) was used to build the online survey battery. The link to the confidential and anonymous survey was sent to participants via Qualtrics' secure site (www. qualtrics.com) following approval from the Human Research Ethics Committee of the University of New England (Approval Number: HE15-087).
Upon opening the survey link, the first page contained the information sheet that briefed participants on the rationale for the research and possible risks involved in participation, that participation was voluntary, and that they could withdraw from the study at any time. The survey took about 10 minutes to complete. At the end of the survey, participants were given two options: (1) either to enter into a draw for a chance to win a prize of AUD$100 by providing their email address; or (2) to exit the survey. They were also informed that it was not possible for their email addresses to be linked to their responses.

Statistical analyses
IBM SPSS Statistical Software version 24 was used to perform missing values replacement and other statistical analyses. Correlations among the variables were assessed using Pearson correlation coefficients. Mediation and moderation analyses were performed using PROCESS v2.16 (Hayes, 2015) with 5000 bootstrap samples.

Results
The results in Table 2 support the first hypothesis that there would be strong correlations among indifference, abuse, over-control, distress, and harmful drinking. All three measures of parenting were significantly associated with higher distress and higher harmful drinking.
Regression analysis showed that 32% of the variance in harmful drinking was explained by sex, age, parenting style, and distress with the strongest predictor being distress, see Table 3.
The next set of analyses examined the relationship between parenting styles, distress, and problematic alcohol use. For this purpose, the MOPS subscales were combined into a single measure of dysfunctional parenting. Moderation analyses failed to find a significant moderating effect, either when the subscales were used separately or as a combined measure.
However, the mediation model was supported, see Figure 1. The indirect effect for distress on the parental style-problematic alcohol use relationship was strong (15%) and statistically significant. Thus dysfunctional parental style relates to increased distress that in turn relates to increased alcohol problems.

Discussion
This study examined the relationship between perceived parenting characteristics, measures of distress, and problematic alcohol use in a sample of predominantly tertiary students from Bhutan. The findings generally confirm what has been found in Western countries (e.g. Bahr & Hoffmann, 2010;Martínez-Loredo et al., 2016;Minaie, Hui, Leung, Toumbourou, & King, 2015). More dysfunctional parental characteristics (abusiveness, indifference, over-control) were significantly and positively related to higher distress and higher alcohol use problems, and males reported more alcohol problems than females.  Note. Fit for model R 2 = .33, Adjusted R 2 = .32, F(4, 202) = 24.98, p < .001. The squared semi-partial (sr 2 ) correlation given is the squared Part correlation from SPSS. The r given is for the zero-order correlation from SPSS. Sex coded as: 1 = male, 2 = female.
In order to understand how these factors relate to each other, various analyses were conducted. Moderation analyses indicated that the relationship between parental characteristics and alcohol problems was neither strengthened nor weakened by distress factors. However, mediational analyses found a significant role for distress factors, suggesting a pathway from negative parental characteristics to greater distress to higher alcohol use problems. The indication is that generalised distress associated with inadequate parenting creates an environment in which negative selfviews develop (McNally et al., 2003) which, in turn, hinder optimum strategies for dealing with feelings of security and anxiety. Exposure to alcohol and perhaps other situational factors associated with alcohol use (e.g. alcohol consuming peers) may act as negative reinforcers encouraging the development of alcohol use as a regulating mechanism for whenever these feelings arise.
The findings reported here show a striking similarity with findings reported from many Western countries which show that greater problematic use of alcohol is consistently associated with the self-reported experience of depression, anxiety, stress, and hopelessness (Boden & Fergusson, 2011;Holahan, Moos, Holahan, Cronkite, & Randall, 2001;Kushner, Abrams, & Borchardt, 2000). So despite the protected Bhutanese traditional culture, the predominant Buddhist philosophy, the focus on Gross National Happiness, and a lack of colonial domination (Subady et al., 2013), similar human experiences find themselves being related to problematic alcohol use. In terms of suggestions for intervention and prevention, strategies that encourage less abuse, neglect, indifference, or over-control, may well be worthwhile (e.g. How-to Parenting Program; Joussemet, Mageau, & Koestner, 2014). However, Harlaar et al. (2008), in an extensive study examining genetic bases for MOPS factors, argued that such an intervention is unlikely to be effective. A more effective strategy is to focus on parent-child interactions such as parental response to genetically influenced temperament, such that parental responses to a disruptive or "difficult" child may be managed in a more sensitive or patient manner than a negative or punitive manner. Similarly for children showing more internalising behaviours, a more understanding, patient, and sensitive manner to behaviour management may result in more resilient and adaptive self-views being developed.

Limitations and conclusion
The results of the present study indicate similar relationships among parenting variables, general distress, and problematic alcohol use as has been found in Western countries. However, many factors limit the confidence with which these results can be generalised to the Bhutanese population in general. A cross-sectional design, a limited sample of mostly tertiary students, self-report measures of parenting characteristics, participants recruited from treatment programs, and limited measurement of alcohol use all contribute to cautionary acceptance. In particular, longitudinal designs are needed to more clearly establish the validity of recalled parental style and the progression from early childhood environment to distress and finally to problematic alcohol use. People with a tendency toward problematic alcohol use may exhibit general anxiety issues which influence their recall of parenting styles (Widom, Raphael, & DuMont, 2004). Sensitivity to Mediation effect size R 2 = .15 [.09, .23]. The parental style measure is based on the combined parental styles of indifference, abusive, and overcontrolling. Distress is based on depression, anxiety, stress, and hopelessness parental behaviours, rumination, worry, and internalisation may be the central factors that influence recall of parental behaviours and contribute to the strong reinforcing effects brought about by the relaxing effects of alcohol.
In addition, there may well be other variables not included in the present study which may be relevant to the developmental trail that leads to problematic alcohol use. Of note here is the role of parental modelling of drinking behaviour, which has been shown to have a significant effect in Western studies (e.g. Alati et al., 2014;Latendresse et al., 2008). Lastly, despite English being in widespread use and taught from an early age, subtle misunderstandings may have occurred which influence response patterns in unknown ways.
In conclusion, the findings constitute a first step to understanding some of the driving factors of problematic alcohol use in young adults in Bhutan. The key finding was that similar relationships exist among parenting styles, distress factors, and alcohol use as has been reported in Western countries. This indicates a similarity in the human condition which goes beyond national borders and cultural mores. Wherever alcohol use has spread across the world, the same human vulnerabilities are attracted to its effects.