Alcohol Use and Its Associated Factors among Adolescents Aged 15–19 Years at Governmental High Schools of Aksum Town, Tigray, Ethiopia, 2019: A Cross-Sectional Study

Introduction The impact of alcohol use among adolescents is multidisciplinary and affects the adolescent's academic performance, precipitates with sexually transmitted infections or psychiatric disorders, and disturbs the social domain of adolescents. Therefore, this study aimed to assess the prevalence and associated factors of alcohol use among adolescents aged 15–19 years at the governmental high schools of Aksum Town, Tigray, Ethiopia, in 2019. Methods A facility-based cross-sectional study was conducted from 1 to 30 January 2019 at Aksum town high school. Alcohol use was assessed by asking the question “have you used at least one of the alcoholic beverages in the last three months for nonmedical purposes?” Study participants were selected using a simple random sampling technique. Data were collected with face-to-face interview and were analyzed using the Statistical Package for the Social Sciences version 22. Bivariate and multivariate logistic regressions were used to see the association between alcohol use and associated factors. Adjusted odds ratio at a p value < 0.05 with a 95% confidence interval was taken to declare the statistical significance of variables. Result About 633 adolescents aged 15–19 years were addressed with a response rate of 99.7%. Prevalence of alcohol use was found to be 39.7% [95% CI (35.7, 43.6)]. Being male [AOR = 1.80; 95% CI (1.24, 2.60)], fathers' educational status 1–8 grades [AOR = 2.98; 95% CI (1.60, 5.53)], fathers' occupation farming [AOR = 4.24; 95% CI (2.038.85)], experienced parental neglect [AOR = 1.75; 95% CI (1.20, 2.55)], strong social support [AOR = 1.79; 95% CI (1.11, 2.87)], and family size of greater than five [AOR = 2.03; 95%CI (1.39, 2.97)] were factors identified to be significantly associated with alcohol use among adolescents aged 15–19 years. Conclusion In the current study, the prevalence of alcohol use is found to be high when compared to other populations. A strong association has been found between alcohol use and lower paternal educational status and farming as an occupation of parents. There should be a regular awareness creation program for parents with lower education about the devastating effects of alcohol on adolescents.


Introduction
According to World Health Organization (WHO), alcohol use is defined as a nonmedicinal consumption of psychoactive substances like beer, wine, and whiskey and other alcoholic beverages that have dependence-producing properties which have been widely used in many cultures for centuries [1]. Psychoactive substance use such as alcohol use is a harmful practice when it surpasses the usual recommended dosage. e long-term practice of such harmful practice converts the need to use it to compulsory because of the strong desire to take the drug despite harmful consequences [2]. Worldwide, data indicated that ethanol use is among the significant risk factors for increased morbidity and death rate as well as social disadvantages [3,4]. It is responsible for the death of 25 million people each year worldwide [1].
Even though the burden is worldwide, developed countries bear significantly higher figures in mortality rates.
e World Health Organization (WHO) report in 2004 for the European region showed that alcohol use is responsible for 11% of male deaths [5]. Alcohol use has been recognized as a significant public health issue and imposed an enormous impact on the economy worldwide. Recently, low-and middle-income countries have also reported that alcohol use is incredibly increasing in their communities, including in school-going adolescents [6][7][8].
e harmful effect of alcohol overweighs among adolescents as it is a critical age group. e impact of alcohol use among adolescents is multidisciplinary and affects the adolescent's academic performance, precipitates to sexually transmitted infections or psychiatric disorders, and disturbs the social domain of adolescents [9]. Furthermore, alcohol use at an early age is reported as it determines adolescents' overall health, sociocultural relationships, and economical status [10,11].
Studies conducted in different countries, including developing countries, showed that there is an alarming figure on the magnitude of alcohol use among adolescents. e prevalence of alcohol use was reported to be 39.1% in South Africa among high-school adolescents [12], 15% in Kenya [13], and 57.7% and 19.2% in Ethiopia [14].

Justification of the Study.
Even though some studies tried to report the magnitude of alcohol use among adolescents, the attention given to interventional policies is minimal. Besides, no study reported its magnitude among a specified age group of late adolescents (i.e., 15-19 years) and evaluated the association between alcohol use and parental treatment and family size of adolescents aged 15-19 years particularly in developing countries. Besides, the late adolescent age group is a stage of life in which adolescents may experience many stressful situations including academic and familyrelated stresses; this may in turn lead them to use alcoholic beverages as a treatment to get out of their stress [15,16]. Unless such an influential public health condition on this significant age group is identified and intervened early, it will impose an enormous negative outcome on the community health at large. We found that depicting the magnitude of alcohol use and its associated factors among adolescents aged 15-19 years is pivotal to come up with an effective intervention. erefore, this study aimed to investigate the prevalence of alcohol use and its associated factors among adolescents aged 15-19 years in Ethiopia.

Study Design, Period, and Setting.
is facility-based cross-sectional study was conducted from 1 to 30 January 2019. Adolescents aged 15-19 years at governmental high schools of Aksum town were the target population. Aksum is located in the Tigray region which is 1024 kilometers far from Addis Ababa. Governmental high schools in Aksum town included in this study were Aksum secondary school, Atse/Kaleb secondary school, and Kedamay Menelik secondary school. A total of 4820 adolescents (2579 in grade nine and 2241 in grade ten) were enrolled as students in accessed high schools.

Sample Size Calculation and Sampling
Procedure. e study sample size was calculated by using a single population formula taking the following considerations: 95% confidence interval (CI) and 4% marginal error, the proportion of alcohol used 40.9% from the previous study [17], and a nonresponse rate of 10%. e final sample size was taken to be 639. Equal chance to participate was given for all governmental high schools of Aksum town. e numbers of students from each governmental high school were selected proportionally to their total number of students enrolled. Finally, respondents were selected for the study by a simple random sampling, that is, lottery method.

Data Collection Instruments and Techniques.
Face-to-face interview was conducted to collect the required information. Initially, the screening tools and other developed structured questionnaires in English language were translated to Amharic and Tigrigna and back to English by an independent person to check for consistency and understandability of the tool. We appointed six data collectors, and the collection process was supervised by the study investigators. Data collectors were trained for clarity of questionnaires and ethical issues.
Alcohol use among adolescents aged 15-19 years was collected by asking a question "have you used/drunk at least one of the alcoholic beverages (beer, wine, whiskey, Areke, Tela, Tej, etc.) for nonmedical purposes within the last three months?" which was answered by "YES" or "NO." Depressive symptoms were assessed by using a multipurpose instrument PHQ-9. PHQ-9 score of greater than or equal to 10 has sensitivity and specificity of 88% for major depression [18].

Operational Definitions
Adolescents: For this study, a school-attending person specifically within 15-19 years of age. Alcohol use: Adolescents who answered YES to a question "have you used/drunk at least one of the alcoholic beverages (beer, wine, whiskey, Areke, Tela, Tej, etc.) for nonmedical purposes within the last three months?" were considered as alcohol users [1,21].

Depression:
ose who score greater than 5 on the PHQ-9 scale [18]. Parental Neglect: ACEQ, which is a self-report instrument covering 10 items, to rate the severity of emotional abuse and neglect, physical abuse and neglect, and sexual abuse [18]. Social support: According to the Oslo-3 Social Support Scale, a score of 3-8 is taken as poor support, 9-11 as moderate support, and 12-14 as strong support [20].

Data Analysis and Interpretation.
After the questionnaire was checked for cleanliness, the data were entered into EpiData 3.1 and exported to SPSS 22 statistical software for analysis. Frequencies, means, percentages, and standard deviations were calculated for sociodemographic and other independent factors. A logistic regression analysis model was conducted. e relationship between each independent variable and the outcome variable was checked by bivariate logistic regression. Independent variables with a p value less than or equal to 0.2 were selected for multivariable logistic regression analysis. Multicollinearity has been checked and chi-square assumptions have been conducted. e significant association of factors was considered at a p value of less than 0.05. e strength of association was evaluated using 95% CI and adjusted odds ratio. e model fitness of multivariate regression has been checked by Hosmer-Lemeshow test (p value � 0.057).

Sociodemographic Characteristics.
A total of 633 individuals participated in the study with a response rate of 99.06%. More than half, 54.3% (344), of the study participants were female students. e majority of the participants, 69% (437), were orthodox Christians. Regarding the educational level of students, 52.3% (331) were grade nine students and the rest of them, 47.7% (302), were grade ten students. 67.6% (428) of the study participants were from urban areas as regards their residence (Table 1).

Social Support Related Factors.
As measured by a threeitem Oslo Social Support Scale, 45.8% (290) of adolescents reported that they received poor social support and 32.2% (204) received moderate social support. e rest have been found to be in a strong or good social support level ( Figure 1).

Clinical and Behavioral Factors.
In addition to current alcohol use by adolescents aged 15-19 years, cigarette smoking and Khat chewing behavior as well as sexual behavior of students were assessed. According to the results, 3.5% (22)  were also screened and the results indicated that about 36% (228) of the students reported that they are neglected either by their parents, caregivers, or guardians. e sexual behavior results showed that 15.6% (99) of adolescent students aged 15-19 years participated in at least one risky sexual behavior.

Prevalence of Alcohol Use and Associated Factors.
e overall prevalence of current alcohol use among adolescents aged 15-19 years at high schools in Aksum town was found to be 39.7% (95% CI; 35.7, 43.6). Slightly increased prevalence of alcohol use has been found among grade ten students (74/302) and male students (98/344) when compared to grade nine students (67/331) and female students (43/ 289), respectively. e bivariate analysis results showed that variables such as sex of the participant, family size, residence of participants, fathers' educational status, fathers' occupation, and comorbid cigarette smoking lifetime and, within the last three months, level of social support and having experienced parental neglect were found to have a p value of less than 0.2. Multicollinearity between independent variables has been checked and chi-square assumptions were done. According to the result, all values of VIF were <1.08 and the correlation coefficient between each variable was less than 0.6. ese factors were entered into a multivariate analysis and the results depicted that being male, having a father whose educational status is 1-8 grades, having a father whose occupation is farming, having experienced parental neglect, having poor social support, and increased family size were found to have a statistically significant association with alcohol use among adolescents aged 15-19 years at a p value less than 0.05. e odds of using alcohol among male adolescents aged 15-19 years are 1.80 times higher when compared to those of females [adjusted odds ratio (AOR) � 1.80; 95% CI (1.24, 2.60)]. Adolescents aged 15-19 years whose fathers' educational status is 1-8 grades were 2.98 times more likely to use alcohol than adolescents whose fathers' gaining certificate and above in their education [

Discussion
is study showed that the overall prevalence of alcohol use among adolescents aged 15-19 years is 39.7%. is is in line with studies conducted in South Africa (39.1%) [12] and the United States of America (41.8%) [22]. However, this result on the prevalence of alcohol use among adolescents aged 15-19 years was lower than those of two other studies done in Addis Ababa, Ethiopia (45.7%) [23], and in Kisumu, Kenya (51.9%) [24]. e possible explanation for the difference might be the difference in study participants in which a Kenyan study included adults of college students [24] and all adolescents were addressed in a study in Addis Ababa, Ethiopia [18], and patterns of alcohol use assessed in which long-term alcohol use was assessed in a study conducted in Kenya [24] and Addis Ababa, Ethiopia [23].
On the other hand, the result of this study on the prevalence of alcohol use among adolescents aged 15-19 years was found to be higher than those of studies done in the Eastern part of Ethiopia 22.2 and 10.4% for lifetime and past one-month alcohol use [25], another study in Ethiopia 19.4% [14], a study from Kenya 15% and 14% in urban and rural schools, respectively [13], a study from ailand 14.8% [26] and another from Zimbabwe 15.6% [27]. Such discrepancies might be due to differences in patterns of alcohol use assessment in which one-month alcohol use was assessed in a study from Ethiopia [25] and another from ailand [26] and the sample size used in which higher sample sizes were used in previous studies [26,27]. Another possible explanation for the discrepancies might be the difference in the study population in which a separate residency of adolescents was compared in a study from Kenya [13] and participants included in which adolescents aged 12-15 years were studied in ailand [26].
Besides, the late adolescence age group is a transition from adolescent to early adulthood. e increased chance of late adolescents to experience different stressful situations like increased academic stress, peer influence, family-related stress, and stress related to physical and physiological changes might contribute to the higher prevalence of alcohol use in this age group as they may use alcohol as a stress selftreatment method [28][29][30][31].
Regarding the factors associated with alcohol use, our study revealed that being male, having a father learning 1-8   grades, having fathers whose occupation is farming, having experienced parental neglect, having poor social support, and increased family size were significantly associated with alcohol use among adolescents aged 15-19 years at a p value less than 0.05. e odds of using alcohol among male adolescents aged 15-19 years are 1.80 times higher when compared to those of females. is is in line with a study done in the Eastern part of Ethiopia (AOR � 2.09) [25], another study conducted on students of Jigjiga University (AOR � 2.12) [32], and a study done on students of Aksum University (AOR � 2.12) [33].
is association might be because males have been reported to be greatly involved in risky behaviors than females [34,35]. is might also be due to the cultural influences among males to practice using alcoholic beverages for different purposes [36]. Besides, the difference might be because alcohol is consumed more by males than by females as a means of stress relieving and for recreational purposes [37,38].
Adolescents aged 15-19 years whose fathers' educational status is 1-8 grades are 2.98 times more likely to use alcohol than adolescents whose fathers' graduated with certificates and above.
is result has been supported by a study conducted in Nepal [39]. is association might be because of the lower educational status of parents influencing their ability to address information regarding the harmful effects of using alcohol [40,41]. Besides, parents of adolescents with lower educational status are more likely to use alcohol, which bears a significant impact on adolescent's alcohol use [42]. Low paternal education may also contribute to their adolescences practicing alcohol use as a means of stress relieving, since they are less likely to learn how to set goals to cope with stress and apply other methods [43].
Adolescents aged 15-19 years whose fathers' occupation is farming were 4.24 times more likely to use alcohol than those whose fathers' are private employees. is has also been supported by a study conducted in Nepal [39]. e possible reason for such association might be because the fact that most farmers have lower educational status [44].
is in turn contributed to continued alcohol drinking despite its harmful effects and later this becomes practiced by their children [45,46]. e probability of using alcohol among adolescents aged 15-19 years who had experienced parental neglect increased by 75% when compared to their counterparts. is has been supported by different studies [47,48]. is might be because adolescents experiencing maltreatment and neglect are more likely to develop emotional disorders, which may enforce them to use alcohol as a self-treatment to get out of that emotional feeling tone [18,46,49]. e odds of using alcohol among adolescents aged 15-19 years who are getting strong social support are 1.79 times higher when compared to those who are getting poor social support. is study has been supported by a study conducted in India [50]. is might be because there is an increased chance of continuously using alcoholic beverages as far as adolescents get support for alcohol-related expenses [51]. It might also be due to the increased peer pressure to drink alcohol when adolescents have many people around [52].
Adolescents aged 15-19 years who are from a family size of greater than five are 2.03 times more likely to use alcohol when compared to those from a family size of less than or equal to five. is might be because parents may not get a chance to supervise their children as they have an increased number of children [53]. e increased family and social problems when family size increases might also be another contributing factor to the increased prevalence of alcohol use among adolescents [54].
e recruitment of high sample size for the study can be mentioned as the strength of this study. Another quality of this study is that we applied a probability sampling technique during selecting study participants. e study might be affected by recall and social desirability issues as the data collection was interview-administered.

Conclusions and Recommendations
e prevalence of alcohol use among adolescents aged 15-19 years was found to be high. Being male, 1-8 grades of father's educational status, fathers' occupational farming, having experienced parental neglect, strong social support, and family size of greater than five were factors identified to be significantly associated with alcohol use among adolescents aged 15-19 years.

Data Availability
e raw data used to support the findings of this study are available from the corresponding author upon request.

Ethical Approval
Ethical approval was obtained from the ethical review board of the Institute of Health, Aksum University.

Consent
Written consent was asked from each selected student after they are informed about the nature, purpose, benefits, and adverse effects of the study and invited to participate. Written assent for those below 18 years of age was also obtained from their parents/guardians/teachers. Confidentiality was ensured. Participants were strictly informed that they have the right to refuse or discontinue participation at any time.