Awareness and Attitudes of Mongolian Adolescents and Youth toward Alcohol Consumption and Alcohol-related Harm.

BACKGROUND: This study aimed to examine alcohol consumption among Mongolian adolescents and youth, as well as their awareness and attitudes toward alcohol-related consequences.
METHODS: We analyzed cross-sectional data collected from students in secondary schools, colleges, and universities in Ulaanbaatar, Mongolia, using descriptive analysis methods.
FINDINGS: More than half of respondents had tried alcohol in the past, and 15.9% of high school students and 58.8% of university students had consumed alcohol in the last month (P = 0.0001). In total, 70.0% of respondents celebrated holidays with alcohol, 23.4% had economic problems due to alcohol consumption, 7.8% had health problems 1-2 times in the last 30 days, and roughly 36.0% had negative attitudes toward alcohol. Approximately, 15.0% of adolescents and young people had an insufficient understanding of anti-alcohol measures and laws.
CONCLUSION: Our findings suggest that Mongolian adolescents and youth have a high level of alcohol consumption and insufficient awareness and attitude regarding alcohol-related harm.

Introduction

Harmful alcohol consumption is a significant public health issue and a risk factor for disease burden, causing substantial health loss worldwide. According to recent studies, more than two billion people or about three of ten individuals are current drinkers globally, alcohol use was the seventh leading risk factor for premature death and disability, and three million deaths were attributed to alcohol use.1-4 Previous epidemiological studies have found the alcohol-associated adverse effects on various health outcomes, such as cardiovascular disease (CVD),5 cancer,6 injuries,7 and mental health.8,9 Alcohol drinking among adolescents can have serious consequences, including neurocognitive effects.10 In addition, despite growing evidence, the contribution of harmful alcohol use to the disease burden of infectious diseases including human immunodeficiency virus (HIV) infection, tuberculosis (TB), and hepatitis, as well as sexually transmitted infections (STIs), has yet to be sufficiently recognized and addressed in relevant global strategies and action plans.11

In Europe, a Polish study found that alcohol, cigarette, and illicit substance use in Poland was high and increasing, despite globally designed preventative actions.12 Moreover, parent awareness of alcohol, cigarette, or illicit substance use in children is low, and schools hardly fulfill their educational and protective roles.12 According to recent surveys, the number of young alcohol drinkers is, in fact, on the rise.3,13,14 For example, young European adults reportedly experienced being drunk more than their counterparts in the world, with 39% of European students reporting that they had been drunk in the last 30 days.14 In addition, a recent study has reported that adolescents who drink alcohol before the age of 15 are four times more likely to develop alcohol dependency than those who wait until they are 21 years or older.15 Furthermore, Iranian cross-sectional study found that the high school students start drinking alcohol at age 14.6 on average.16 Meanwhile, another study showed that in the students of the first and second grade in high schools of Kerman, Iran, the use of alcohol was 30 percent. Unfortunately, the experience of using alcohol among students at public schools was more than private school students.17

According to a report by the World Health Organization (WHO) in 2021, the highest alcohol consumption among men and women in 2019 was in the European Region, the Region of Americas, and the Western Pacific.18 An African cross-sectional study found that South Africa had the highest levels of alcohol consumption per adult drinker than any other region in the world.19 Moreover, risky drinking patterns start at age of 15-24 years and continue into adulthood,20 making this group a target for intervention.

One Asian review reported that the current drinking prevalence among young people markedly differed among eight Asian countries included in the review, ranging from 4.2% in Malaysia to 49.3% in China.21 In most Asian countries, over 15.0% of total deaths among young men and 6.0% among young women aged 15-29 years were attributable to alcohol use. Alcohol use among young people is associated with many harmful outcomes, including stress, family violence, injuries, suicide, and sexual and other risky behaviors. Heavy and risky drinking was common among young people, and those under age 35 had the highest levels of risky drinking practices in a study in Mongolia.21

According to a Mongolian national population-based survey, approximately, 50% of men and 30% of women are current alcohol drinkers. Moreover, 9 in 10 respondents agreed that heavy episodic drinking was common among Mongolians, suggesting that the harm of daily alcohol consumption is generally perceived as being high.22 However, little is known about effective strategies to reduce alcohol consumption and alcohol-related harm. In addition, the association between alcohol use and its outcomes in adolescents and young adults has not been widely studied in Mongolia. Accordingly, in the present study, we investigated alcohol consumption among Mongolian adolescents and youth, as well as their awareness and attitudes toward alcohol-related consequences.

Methods

Study design: This study adopted a cross-sectional design and targeted secondary school, college, and university students. The survey was conducted in 2017 and a quantitative research method was used for data collection.

Study participants: A total of 473 students aged 15-24 years were simply and randomly selected from five high schools, three colleges, and seven universities in Ulaanbaatar, Mongolia.

Inclusion criteria

Students who agreed to participate in the survey, with consent from their parents or legal guardians.

Students who were studying at a secondary school, Vocational Training Center (VTC), college, or university at the time of the survey, and were aged between 15-24 years.

Survey data and materials were collected by questionnaire.23 Utilizing several recourses such as global school-based survey questionnaire, nationwide research questionnaire to define risk factors of non-communicable diseases (NCDs),24 and Mongolian law provisions on fighting against alcoholism, we have developed a customized questionnaire to collect information on alcohol consumption and its harms among adolescents and youth. The customized questionnaire had seven sections: alcohol consumption among young people, the causes of alcohol use, the influences from environment, the consequences (for individual, others, and community) derived from alcohol drinking, the knowledge on laws and regulations concerning alcoholic beverages, the ways to reduce alcohol consumption (laws, friends’ positive influences, etc.), and school-based measures against alcoholism. Including: general information and alcohol consumption, psychological consequences derived from alcohol consumption, law enforcement assessment (some provisions contained within a law on fighting against alcoholism), ways to reduce alcohol consumption, and measures carried out to decrease harmful use of alcohol in school zones.23

Alcohol consumption was measured and evaluated using a “standard drink” unit, defined as 10 grams of ethyl alcohol contained in any alcoholic beverage (Table 1).

Table 1

Average number of standard drinks (alcoholic beverages) consumed in one occasion

Type of alcohol	Size	Ethyl alcohol		Number of standard drinks
		Distilled spirits (%)	Liquid (g or ml)
Vodka	1 shot/50 ml	40.0	20.0	2.0
Beer	1 can/330 ml	4.0-5.0	15.0	1.5
Wine	1 glass/100 ml	12.5	12.5	1.3
Home-made distilled vodka	1 cup/100 ml	15.0	15.0	1.5
Airag/fermented horse milk	1 bowl/500 ml	5.0	5.0	2.5

Alcohol consumption within the last one month was determined by how many times respondents consumed a “standard drink” on one occasion, e.g., a glass of wine (100 ml), a can of beer (330 ml), a cup of vodka, whisky, or liquor (50 ml), a cup of dairy-derived alcohol (100 ml), or a bowl of mare’s fermented milk (500 ml). Drunkenness was defined by the following symptoms: impaired balance, staggering, slurred speech, and vomiting. The level of alcohol use was determined by the CAGE test,25 a short and rapid screening tool. This test has several advantages, such as being applicable to any population, reliable and valid for assessing alcohol abuse (90% probability), requiring a short amount of time to administer, not requiring the presence of an addiction specialist, and easily answered and understood by respondents. The acronym “CAGE” represents four questions that comprise the test, each of which is designed to assess problem of drinking and potential alcohol problems.

The following response interpretations were used:

One “Yes” answer indicates that the respondent consumes alcohol in small amounts.

Two “Yes” answers indicate that the respondent is likely to drink excessively.

Three “Yes” answers indicate that the respondent is likely to be alcohol-dependent.

Four (all) “Yes” answers indicate that the respondent is alcohol-dependent.25

All participants provided written informed consent before participating in the study. The study protocol was approved by the Ethics Committee of Mongolian National University of Medical Sciences, Ulaanbaatar (No.: 03/2017-06/2017).

All statistical analyses were performed with SPSS software (version 20, IBM Corporation, Armonk, NY, USA). Frequency, percentage, mode, and median were used for continuous variables, and the chi-square test was used for categorical variables. P < 0.05 was considered statistically significant.

Results

Summary statistics of survey responses revealed that 70.6% of participants were in the age group of 15-19 years, and 29.4% were in the age group of 20-24 years. Over 63% of participants were men and 27% were women, roughly 60% were university or college students, and 40% were primary school students (Table 2).

Table 2

Characteristics of survey respondents

Characteristics	n (%)
Age group (year)
15-19	334 (70.6)
20-24	139 (29.4)
Sex
Men	301 (63.6)
Women	172 (36.4)
School
Middle and high school	180 (38.1)
College	70 (14.8)
University	223 (47.1)
Family size
1-3 members	79 (16.7)
4-5 members	295 (62.4)
6 or more	99 (20.9)
Wife/husband	14 (3.0)
Father/mother	274 (57.9)
Grandfather/grandmother	46 (9.7)
Siblings	65 (13.7)
Cohabitant	8 (1.7)
Relatives	30 (6.3)
Friend	21 (4.4)
Alone	7 (1.5)
Other/children	8 (1.7)

About 57% of participants responded that they had tried alcohol at least once in their life. A total of 36.8% of participants had experience of getting drunk at least once in their life, and this response was significantly associated with age group (P = 0.013).

The rate of alcohol consumption was especially high among university students (66.5%, P = 0.001), with 40.2% responding that they consumed alcohol during celebrations (Table 3).

Table 3

Alcohol consumption by age group and school

Alcohol consumption	Total	Age group (year)		P	School			P
		15-19	20-24		Middle and high school	College	University
	n (%)	n (%)	n (%)		n (%)	n (%)	n (%)
Trying alcohol at least once	269 (56.9)	173 (51.8)	96 (69.1)	0.040	60 (22.3)	30 (11.2)	179 (66.5)	0.001
Experiencing intoxication at least once	174 (36.8)	103 (30.8)	71 (51.1)	0.013	34 (19.5)	18 (10.3)	122 (70.1)	0.109
Celebration	190 (40.2)	109 (32.6)	81 (58.3)		32 (16.8)	18 (9.5)	140 (73.7)
Imitating other friends	0 (0)	0 (0)	0 (0)	0.120	0 (0)	0 (0)	0 (0)	0.170
Being accepted by others	2 (0.4)	1 (0.3)	1 (0.7)		1 (50.0)	0 (0)	1 (50.0)
Relieving stress	29 (6.1)	20 (6.0)	9 (6.5)		8 (27.6)	2 (6.9)	19 (65.5)

Approximately, 65% of students responded that the alcohol-related law, which states that people under the age of 21 are not allowed to buy or consume alcohol in the workplace or school, was effective or very effective (Table 4).

Table 4

Effectiveness of the anti-alcoholism law by age group, sex, and school

Characteristics	Total	Age group (year)		P	Sex		P	School			P
		15-19	20-24		Men	Women		Middle and high school	College	University
	n (%)	n (%)	n (%)		n (%)	n (%)		n (%)	n (%)	n (%)
How effective are the methods to improve implementation of the law?
Not effective	48 (10.1)	38 (8.0)	10 (2.1)	0.025	31 (10.3)	17 (9.9)	0.013	20 (11.1)	7 (10.0)	21 (9.4)	0.001
Not very effective	46 (9.7)	32 (6.8)	14 (3.0)		32 (10.6)	14 (8.1)		11 (6.1)	2 (2.9)	33 (14.8)
Effective enough	70 (14.8)	48 (10.1)	22 (4.7)		41 (13.6)	29 (16.9)		28 (15.6)	7 (10.0)	35 (15.7)
Effective	118 (24.9)	89 (18.8)	29 (6.1)		76 (25.2)	42 (24.4)		53 (29.4)	14 (20.0)	51 (22.9)
Very effective	191 (40.4)	152 (32.1)	39 (8.2)		121 (40.2)	70 (40.7)		68 (37.8)	40 (57.0)	83 (37.2)
What is the impact of measures that promote not selling alcohol to youth under 21 years of age in order to reduce alcohol consumption among young people?
Not effective	90 (19.0)	68 (14.4)	22 (4.7)	0.006	54 (17.9)	36 (20.9)	0.026	36 (20.0)	16 (22.9)	38 (17.0)	0.006
Not very effective	51 (10.8)	41 (8.7)	10 (2.1)		35 (11.6)	16 (9.3)		24 (13.3)	8 (11.4)	19 (8.5)
Effective enough	67 (14.2)	45 (9.5)	22 (4.7)		39 (13.0)	28 (16.3)		25 (13.9)	3 (4.3)	39 (17.5)
Effective	84 (17.8)	71 (15.0)	13 (2.7)		51 (16.9)	33 (19.2)		28 (15.6)	12 (17.1)	44 (19.7)
Very effective	181 (38.3)	134 (28.3)	47 (9.9)		122 (40.5)	59 (34.3)		67 (37.2)	31 (44.3)	83 (37.2)
How effective is the article of the law that states all promotions/advertisements on alcohol products must have the warning “Over-use of alcohol is harmful to your health” in order to reduce alcohol consumption among young people?
Not effective	85 (18.0)	62 (13.1)	23 (4.9)	0.002	58 (19.3)	27 (15.7)	0.011	30 (16.7)	14 (20.0)	41 (18.4)	0.006
Not very effective	88 (18.6)	66 (14.0)	22 (4.7)		52 (17.3)	36 (20.9)		35 (19.4)	10 (14.3)	43 (19.3)
Effective enough	81 (17.1)	57 (12.1)	24 (5.1)		46 (15.3)	35 (20.3)		30 (16.7)	10 (14.3)	41 (18.4)
Effective	80 (16.9)	66 (14.0)	14 (3.0)		50 (16.6)	30 (17.4)		35 (19.4)	9 (12.9)	36 (16.1)
Very effective	139 (29.4)	108 (22.8)	31 (6.6)		95 (31.6)	44 (25.6)		50 (27.8)	27 (38.6)	62 (27.8)
What is the impact of the article of the law requiring people “not to consume alcohol in the workplace”‌ in reducing alcohol consumption among young people?
Not effective	70 (14.8)	52 (11.0)	18 (3.8)	0.015	53 (17.6)	17 (9.9)	0.052	18 (10.0)	15 (21.4)	37 (16.6)	0.011
Not very effective	42 (8.9)	32 (6.8)	10 (2.1)		20 (6.6)	22 (12.8)		18 (10.0)	8 (11.4)	16 (7.2)
Effective enough	56 (11.8)	41 (8.7)	15 (3.2)		28 (9.3)	28 (16.3)		21 (11.7)	4 (5.7)	31 (13.9)
Effective	111 (23.5)	86 (18.2)	25 (5.3)		71 (23.6)	40 (23.3)		47 (26.1)	13 (18.6)	51 (22.9)
Very effective	194 (41.0)	148 (31.3)	46 (9.7)		129 (42.9)	65 (37.8)		76 (42.2)	30 (42.9)	88 (39.5)

Discussion

The present study found that more than half of adolescents and youth in Mongolia started consuming alcoholic beverages at age of 16, with one in two starting drinking between age of 16-18 years. These findings are consistent with previous reports from most cross-sectional studies that examined the awareness and attitudes of adolescents and youth toward alcohol consumption. For instance, the mean age of starting drinking was reported to be 15-16 years in a Polish study,12 17 years in an Irish study,15 and between 15 and 19 years in eight Asian countries according to data from the WHO’s Global Information System on Alcohol and Health (GISAH) in 2010.18 To our knowledge, the present study is the first to evaluate drinking behaviors and related factors among young adults in Mongolia.

Our survey revealed that beer was the most preferable among alcoholic beverages. We presume that this preference among adolescents and youth may be related to the fact that beer prices are relatively low. Furthermore, our results revealed that the reasons for consuming alcohol among university students were to celebrate holidays or imitate their friends. These findings are consistent with those of a previous cross-sectional study.26,27

1 in 10 respondents had unprotected sex, got injured, or had an accident (e.g., road accident) in the last 30 days before the survey; in a few cases, alcohol consumption affected the respondent’s health. Previous studies in Latin America and the Caribbean reported similar findings, in that alcohol-related injuries most commonly occurred outdoors (36%) while in transit.7 Moreover, 1 in 10 respondents were harmed by friends and others who consumed alcohol, 15.6% did not remember what had happened, and 23.4% experienced financial difficulties at least 1-2 times. Another study reported that 5.6% of people had sleep deprivation related to alcohol, and 40.2% experienced unsafety in public places.9 Alcohol-related unprotected sex was reported by 39.0% of students, and 32.0% reported alcohol use prior to sex.28

The results of our survey suggest that adolescents begin to enjoy drinking alcohol beverages because of how alcoholic beverages are marketed and advertised, which was one of the reasons for alcohol consumption by the young generation. According to Article 5.3 of the Law on Anti-Alcoholism in Mongolia, alcohol labels on bottles, packages, and parcels must contain the trademark, brand name, national standard, composition, alcohol content, type, manufacturing place and date, a health warning, and standard concentration.29 In most countries, labels of alcoholic beverages include warning messages such as “excessive consumption of alcohol is harmful to health” (most South American countries), “not to be sold to anyone under the drinking age”, or “not for sale to persons under the age of 18 years”.30

Among countries that have implemented programs to reduce alcohol use and alcohol-related harm, Belarus and Peru appear to be highly successful. Belarus has adopted the National Program on Prevention of Harmful Alcohol Use (2011-2015). The introduction and implementation of new policies and initiatives to impose sanctions on alcohol advertisements on TV and radio between 07:00 am and 22:00 pm, and to strengthen the control and inspection of home-based alcohol producers have led to a significant decrease in the number of crimes committed due to alcohol use by 6.5% in 2011-2012 and by 11.4% in 2012-2013.31 Botswana has also achieved success by imposing limits on the sale of alcoholic drinks. For instance, alcohol distribution is allowed from Sunday to Wednesday midnight, but forbidden from Thursday to Saturday 3:00 am. A year after implementing these measures, the number of violent deaths decreased by 11%, murder cases by 19%, and accidents involving drunk driving by 28%.32

The present study has limitations which worth noting. First, due to the cross-sectional design, the causality between alcohol and alcohol-related risk factors could not be clarified. Second, the study participants were limited to adolescents and youth in Ulaanbaatar. Thus, future studies should expand the study population to encompass all age groups and living areas.

Conclusion

The present study revealed that the alcohol consumption was relatively high among Mongolian adolescents and youth. Our results suggest that adolescents and youth with high levels of alcohol consumption may represent a target population for further examination of alcohol-related harm.

The importance of health education has been emphasized in efforts to reduce alcohol consumption and alcohol-related harm. In some countries, health education and life skill training courses are included in the core curriculum of secondary schools, and each school designs its own programs and provides the opportunity to study outside the classroom in both core and elective courses.28,33