Problematic Alcohol Use among University Students

Background Alcohol is attributable to many diseases and injury-related health conditions, and it is the fifth leading risk factor of premature death globally. Hence, the objective of this study was to assess the proportion and associated factors of problematic alcohol use among University students. Material and methods Cross-sectional study was conducted among 725 randomly selected University students from November to December 2015. Data were collected by self-administered questionnaire, and problematic alcohol use was assessed by Alcohol Use Disorder Identification Test. Chi-square test was used to show association of problematic use and each variable and major predicators was identified using logistic regression with 95% confidence interval (CI); and variables with p-value less than 0.05 were considered statistically significant. Results About 83 (11.4%) of the samples were problematic alcohol users of which 6.8% had medium level problems and 4.6% had high level problems. Significantly associated variables with problematic alcohol use among students were presence of social phobia (AOR = 1.7, 95% CI: 1.0, 2.8), lifetime use of any substance (AOR = 6.9, 95% CI: 3.8, 12.7), higher score in students cumulative grade point average (AOR = 0.6, 95% CI: 0.4, 0.9), and having intimate friend who use alcohol (AOR = 2.2, 95% CI: 1.3, 3.8). Conclusion Problematic alcohol use among university students was common and associated with social phobia, poor academic achievement, lifetime use of any substance, and peer pressure. Strong legislative control of alcohol in universities is important to reduce the burden of alcohol.

Alcohol misuse was also reported as a strong predictor of students' mental health in which, it was attributable for increased depressive symptoms accompanied with drinking to cope (3,4), attempted suicide and self-harm behaviors (5,6), and aggressive behaviors (7). Alcohol use was also associated with the use of novel psychoactive substances, a new trend exacerbated by the presence of alcohol (8). Moreover, students with problematic alcohol use are less likely to seek professional help for their mental health problem (9). Problematic alcohol use contributes to a significant proportion of students' engagement in risky sexual behavior (10), poorer executive functions (11), and poor academic achievement (12)(13)(14).
The prevalence of problematic alcohol use in university students was widely variable and generally higher in developed countries (15). Students' alcohol use in general ranged from 22 in Ethiopia to 94% in Ireland; and problematic alcohol use ranged from 2.5 in Germany to 53% in Ireland (15)(16)(17)(18). In developed countries, on average, each student had 1.7 drinks daily with about three episodes abusive drinking per month and about 10% of probable alcohol dependence (18,19). Alcohol was also common in Ethiopian university students in which 31% of students in Addis Ababa University and about 50% in Haramaya University reported current alcohol use (20,21). Students consumed alcohol for the reason of social gathering and as the means of social interaction influenced by their peers (16,19,22). Many predictors of problematic alcohol use have been identified previously. Sex, socioeconomic status, living in dormitory with higher number of roommates, cultural norms about alcohol, and having families who use substance were the commonly mentioned factors affecting students' problematic alcohol use (5,16,23,24).
Problematic alcohol use by university students is an important public health issue due to its multiple and wide range of effects on physical, psychosocial, and mental health. Despite some researchers tried to show the prevalence of alcohol use among university students in Ethiopia, there is little/no evidence on how many of those students engaged in problematic alcohol use and probable alcohol dependence. Therefore, it is very important to conduct surveys on students' alcohol use problem by including further possible predictors. Hence, the purpose of this study was to assess the level of problematic alcohol use and predictor factors among university students.

MaTerials anD MeThODs
Cross-sectional study was conducted among 725 randomly selected Wolaita Sodo University regular students from November to December 2015. Wolaita Sodo University is one the government owned Universities in southern Ethiopia. Regular students enrolled in the University in 2015/16 academic year were included in the study.
Problematic alcohol use was the outcome variable; and the independent variables were sociodemographic variables (sex, age, marital status, religion, residence, monthly pocket money, and ethnicity), substance use related variables (having intimate friend who use alcohol, parents alcohol use status, and lifetime substance use), and other variables (students' interest in their field of study, any disabling or chronic illness, parenting style, and academic performance). Data were collected by pretested self-administered questionnaire by trained data collectors and supervisors. Problematic alcohol use was assessed by Alcohol Use Disorder Identification Test (AUDIT), which was developed by World Health Organization to be used in culturally diversified settings. AUDIT has 10 items in which the first 8 items are Likert scale scored from 0 to 4 and the last two items are scored as 0, 2, and 4. Total score of 8 or more was considered as positive for problematic alcohol use. AUDIT scores in the range of 8-15 represented low level of alcohol problems, whereas scores of 16 and above represented high level of alcohol problems; and AUDIT scores of 20 and above clearly showed alcohol dependence (25). Social phobia was assessed by using the Social Phobia Inventory (SPIN), which was developed by Connor et al. It was 17 items self-rating tool scored from 0 (not at all) to 4 (extremely) and the sum score ranged from 0 to 68 (26). A student with a score of 20 and above on SPIN were considered as having social phobia. The other variables were assessed by structured questionnaire developed by reviewing different literatures; and the responses were based on the students report.
Data were entered in to EPI info software version 3.5.3 and then transported to SPSS version 20 for analysis. Descriptive statistics were used to describe the result with respect to problem alcohol use with corresponding chi-square and p-value. Logistic regression was used to analyze the association between dependent and independent variables. Odds ratios with 95% confidence intervals (CIs) were used to show the strength of the associations, and variables with p-value of less than 0.05 were considered as statistically significant.
Ethical clearance was obtained from institutional review board of Wolaita Sodo University. The purpose of the study was fully explained for all participants in order to give them an informed choice to participate. Confidentiality was maintained by anonymous questionnaire and written informed consent was obtained from each participants.

resUlTs sociodemographic characteristics of respondents
From the total of 740 sample size, 725 participants were included in the study with the response rate of 97.97%. The mean age of the participants was 21.15 years (SD ± 1.7) and the reported monthly pocket money of the students ranged from 50 to 3,600 Ethiopian birr with the median value of 300 Ethiopian birr ( Table 1).
substance Use and related characteristics of the Participants From the total participants, 160 students had parents with alcohol use history and 29 (4%) of them were screened positive for alcohol use problem. Lifetime substance use (alcohol, tobacco products, or khat) was also reported by 240 students ( Table 2).

DiscUssiOn
Approximately 1 from 10 students had problematic alcohol use and 4.6% students were in high level problematic alcohol use, which was indicative for alcohol dependence. The finding was consistent with the Belgian University students in which problematic alcohol use was 14 and 3.6% probable dependence (14). It was also in line with the findings of international study for Bulgaria 9%, France 8.5%, and Hungary 8% (15). However, our finding was generally lower as compared with many other countries' problematic alcohol use among college students. For instance, 47.6% of students in Spain were binge drinkers (27), 61% of students in England were positive for AUDIT scores (18), 40-45% of American college students were heavy drinkers (28), and South Africa 15% (15). The current finding was also much lower than the findings from Belgium 36.5%, Colombia 35%, Ireland 53%, and the study done in Italian young people in which binge drinking was reported by 67.6% of the participants (15,29). The main possible explanation for this difference might be the difference in socioeconomic status of the students. It was suggested by researchers that high socioeconomic status might increase the risk of problem alcohol use (15). Race was also another important explanation for the above discrepancy; the percentage of students who reported hazardous drinking was five times higher in whites than non-whites (18,22,28). Use of self-administered survey in the current study might also underestimate the prevalence of problematic alcohol use. On the other hand, the current finding was higher as compared with findings from Germany, Greece, Romania, and Italy in which students' problem use of alcohol were 2.5-4.5% in those countries (15).
Peer pressure was an important predictor of problematic alcohol use in university students in which the odds of having problematic alcohol use among students who had alcohol user intimate friends were more than two times as compared with their counter parts. Direct or indirect encouragement from intimate friends was indicated as a major factor to be engaged in risk-taking behaviors. Students tend to drink more alcoholic beverages during social gatherings in the virtue of social interaction and high level of alcohol abuse was reported by students living in the dormitory with high density of roommates (19,22,30). In a Kenyan study, 75.1% of students admitted that they were introduced for substance abuse by their friends. Previous studies in Ethiopia also showed the influence of peers on students' alcohol consumption; students whose friends consume alcohol were more likely to consume alcohol (16,31).
Lifetime exposure for substances other than alcohol, like Khat and tobacco products was strongly and positively associated with students' problematic alcohol use. Students who had ever used any substance other than alcohol were about seven times more likely to engage themselves in problematic alcohol use. This was supported by the study conducted in Ethiopia among medical students by which ever use of cigarette or khat was associated with current alcohol use (16). Having history of smoking was associated with higher risk of alcohol use disorder than who never smoked as implicated in previous studies (32). Individuals who used some kind of substance also engaged in further risktaking behaviors like alcohol abuse and subsequent alcohol use disorder (10).
This research showed that high achievement in students' academic performance was associated with low risk of problematic alcohol use. Alcohol abuse has significant effect on executive functions of an individual accompanied with blackouts, frequent injuries, less motivation in activities, and even moderate doses of alcohol use had risk of decreasing academic performance (11,33). Even though there were some differences in male and female students (34), this finding was consistent with other studies conducted in different areas (13,14,35).
The other variable significantly associated with students problematic alcohol use in the current study was probable social phobia. Students who were screened positive for probable social phobia were 1.7 times more likely to have problematic alcohol use and this was supported by other studies in Nigeria and USA (36). This might be explained by the students' tendency to use alcohol as self-medication to get away from their stress and fear (37)(38)(39).
Unlike other studies (16,24,31), sex, marital status, family history of substance use, and student's origin of residence were not associated with problematic alcohol use. Even though the occurrence of problematic alcohol use in male to female ratio was 2:1, it was statistically not significant in the current finding.

limitations of the study
This study did not assess all possible associated substances and did not show the interaction effect of other substance use with problematic alcohol use. Since alcohol is a gateway drug, it is expected that students would also use other drugs in addition to alcohol. Even though we had tried to maintain privacy and encourage the participants to complete the real information, the result might be underestimated due to social desirability bias. The study also did not measure blood alcohol concentration of the participants, which would be very important to assess the current level of alcohol in the blood stream. cOnclUsiOn Significant proportion of students reported problematic alcohol use and was associated with peer pressure, lifetime substance use, poor academic performance, and probable social phobia. Developing preventive interventions focusing on risky behaviors and legislative control in the universities toward alcohol use problem is important. Further research is needed to indicate the combined effect of other substances to problematic alcohol use, and it would be also very important to assess depressive symptoms associated with alcohol.

eThics sTaTeMenT
Ethical clearance was obtained from institutional review board of Wolaita Sodo University. The purpose of the study was fully explained for all participants in order to give them an informed choice to participate. Confidentiality was maintained by anonymous questionnaire and written informed consent was obtained from each participants.

aUThOr cOnTriBUTiOns
All authors contributed equally for the whole process of this study. All authors read and approved the final manuscript.

acKnOWleDgMenTs
Our grateful thank goes to the study participants for their genuine participation in this research and Wolaita Sodo University for financial support.