Alcohol has a fundamental role in Australian life. As an accompaniment to social and recreational activities, it is used to celebrate, commiserate and relax1. Alcohol consumption plays an important role in adolescent culture, as a part of group activity and peer group norms. Many adolescents drink alcohol with the aim of getting drunk quickly, which they view as being 'out of control'2. Of concern is the fact that drunkenness is not seen by adolescents as harmful2.
Australia's tolerance of drunkenness is mirrored in the level of drinking by adolescents. Consumption of alcohol among secondary school students becomes more common with increasing age3. In 2001, more than one in four adolescents aged 14-19 years consumed alcohol weekly4, and one in nine adolescents consumed alcohol in patterns that were considered to be risky or high risk in the long term. One in 10 adolescents consumed alcohol at least weekly, in a way that was considered to be risky or high risk to their health in the short term4. While underage drinking is not new, the proportion of underage drinkers and the amount of alcohol they are drinking is at record levels2,3.
Early access to alcohol has been correlated with early binge drinking, which in turn is predictive of later elevated alcohol consumption, health and social problems5,6. Long and short-term risky or high risk drinking has been associated with negative physical, emotional and social consequences7. Among young people aged 16-24 years, alcohol related harm is one of the leading causes of disease and injury burden8. Such harms include road trauma, depression, suicidal behaviour, decreased scholastic and sporting performance, aggression, assault, disrupted family relationships, high risk sexual activity and delinquent behaviour9.
Youth in rural areas have poorer health status than their metropolitan counterparts, as demonstrated by higher death and hospitalisation rates, with road trauma and suicide the leading causes of death10. This is compounded by poorer access to mental health primary care services in rural and regional areas11. In 2004, less than a quarter of all those killed on Victorian roads had a blood alcohol concentration of 0.05 or more12. Of these, 53% were killed on country roads12. The 18-25 year old group represented 14% of Victorian vehicle licence holders yet accounted for 27% of the drivers killed13.
Rural youth face geographical isolation and structural disadvantage (socio-economic disparities, limited educational, employment and recreational opportunities, and reduced access to health care services)14, which is reported to contribute to risk-taking behaviour15,16. This may help to account for adolescents in rural areas being more likely to consume alcohol and suffer from the effects of risky/high risk drinking than their metropolitan counterparts17,18. Adolescents in rural areas are also more likely than urban adolescents to attribute early alcohol initiation to external factors, such as advertising, legal issues, easy access to alcohol2 and affordability19.
Parents are the principle influence on the behaviour and attitudes of their children across a wide range of domains and they become 'gatekeepers' with respect to alcohol when their teenagers reach adolescence. As such they are a salient group to consider in relation to adolescent alcohol use. Many parents do not realise how important they are as role models in influencing their adolescents' drinking behaviour2,20,21. Parental alcohol use is an important determinant of adolescents' alcohol use22. Thus, adolescents are more likely to drink alcohol if their parents do so22-24. Parental knowledge and tolerance of adolescent alcohol use is varied and ranges from ignorance through to reluctant acceptance or intolerance2. While parents acknowledge that they have a responsibility to be role models and to teach adolescents about safe alcohol consumption and prevention of alcohol related harm, many parents see themselves as ineffective in these roles and unable to accept primary responsibility for these tasks2. Parents often feel powerless to do anything about their teenagers' drinking and often reassure themselves that 'at least they are not using drugs'25. They feel uninformed about the nature and extent of the harmful use of alcohol, and want advice on how to positively encourage safe drinking behaviours2,26.
The Australian National Alcohol Strategy1 aims to contribute to the reduction of alcohol related harm by using a harm minimisation framework. This framework is a comprehensive approach to drug-related harm and incorporates supply reduction, demand reduction and harm reduction. The Strategy promotes the active role of parents in educating young people about the dangers associated with risky/high risk alcohol consumption1.
A substantial amount of work has been undertaken internationally about parents' role as educators, and as role models, their tolerance of teenagers' use of alcohol and their perceptions of adolescents' patterns of alcohol use; however there has been limited work undertaken in Australia. Shanahan and Hewitt broadly explored parents' knowledge, attitudes, beliefs, behaviours and views towards teenage alcohol consumption and their perceived ability to respond to young people's alcohol use.2 The present study provides a more detailed examination of these matters with a specific focus on Australian parents in rural and regional areas. The aim of this research was to understand rural parents':
- attitudes, beliefs and concerns with respect to their teenage children's use of alcohol
- perspectives on the way in which they educate and/or provide role models for their teenage children with respect to alcohol usage
- receptiveness to harm reduction strategies.
Qualitative descriptive research methods, were used to collect data about rural and regional parents' experiences of adolescents' alcohol use. While all qualitative approaches include some description, qualitative description is useful as a method by itself as it provides a broad summary of events27. These methods and diverse samples provide the opportunity to learn about a range of opinions, feelings and experiences that people have about a given problem or service but are not intended to provide a representative view of the broader population28,29.
State government, Catholic and independent secondary schools in the north and north-western regions of Victoria, Australia (Fig 1) were invited to participate in this project. This area covers more than one-quarter of the area of the State of Victoria and has a population of 280 447 people, of which 8% were born overseas30. It includes the third largest regional city in Victoria and many smaller regional and remote towns.
Figure 1: Map of the study area, the north and north-western regions of Victoria, Australia.
School principals were sent an information package consisting of a letter of invitation to participate, an article for inclusion in the school newsletter, the research proposal and the ethics approval for the project. Parents were invited to contact the researchers directly if they were interested in participating.
Additionally, articles about the project were published in a local newspaper and state-wide newspaper. Recruitment of participants via schools can often be difficult and so, parents were given the opportunity to participate in either a focus group or one-to-one interview. It was thought that this choice might enhance recruitment. For some parents, discussing their parenting styles in front of other parents (particularly in rural communities where they might be known either personally or professionally) can be difficult. Snowball sampling techniques were also used to increase the number of participants31. A total of 28 parents with adolescent children attended a total of four focus groups and one individual interview, which were conducted by an experienced facilitator and a note-taker.
The semi-structured interview schedule used to guide the focus group discussions and one-to-one interview was developed using current literature and was based on the PRECEDE framework. The PRECEDE framework analyses social concerns, behavioural and non-behavioural factors that contribute to a health problem using predisposing, enabling and reinforcing factors32. Predisposing factors in this study included parents' perceptions of how adolescents use alcohol, their perception of the knowledge and attitude adolescents have toward alcohol and the perceived risks associated with alcohol use. Parents' perception of if and how they influence their children's use of alcohol, parents' access to support and information and adolescents' access to alcohol were considered enabling factors in this study. Reinforcing factors in this study included perceived influences on adolescent alcohol use, such as peers, parents or other role models.
The focus group discussions of 1-2 hours were continued until data saturation was reached. Focus groups and the one-to-one interviews were audio-taped so that the raw data could be transcribed verbatim. The transcripts were independently reviewed by members of the research team to identify the main emerging themes and the sub-themes and determine how these related to both the aims of the study and the experiences of rural parents. The researchers then met and discussed both the major themes and the sub-themes and how these related, in an axial coding framework until consensus was reached. This reconstructive process allowed the researchers to put the data back together in a new way, connecting the themes and their sub-themes. That is, the specific themes identified were put into context by the sub-themes, which gave rise to them.
Ethics approval was gained from La Trobe University, Bendigo, the Victorian Department of Education and Training and the Catholic Education Office. Each participant was provided with an information sheet and invited to sign a consent form prior to participating. A payment of AU$20 was offered to all participants to assist with covering the costs associated with participation.
Results and Discussion
Thematic analysis resulted in identification of four main themes in relation to parents' values, beliefs, concerns, and restrictions on their teenage children's use of alcohol (Appendix I). The relationship between the main themes and sub-themes were grounded in the parents' experiences. Each of the four main themes and sub-themes are described below in the Australian context and in view of the current literature.
Parents' perceptions of adolescent use of alcohol
Parents' perceptions of adolescent patterns of alcohol use included a number of factors including age of initiation to alcohol, what and where they drink.
Age of initiation: Parents agreed that teenagers were typically initiated to alcohol use in the home at 13 or 14 years of age. In 2001, the mean age of initiation to alcohol across Australia was reported as 17 years4. This is somewhat older than the age reported by these rural parents. This variation may be an actual difference or could be attributed to fact that Australian Institute of Health and Welfare (AIHW) data was based on reports by the young people themselves. Alternatively, this difference may be a result of how alcohol use was defined. The AIHW defined age of initiation as the age when one full glass of alcohol was consumed4; whereas, the current study defined age of initiation as when alcohol was first consumed, whether that was a sip or a full glass of alcohol.
Types of drinks: Changing trends in the types of alcohol available and being consumed was a major concern for parents. Pre-mixed drinks were identified as the most common type of alcohol consumed by adolescents. Similarly, other research suggests that the new sweet alcoholic pre-mixed drinks on the market are the preferred choice for adolescents and are also inexpensive33. Parents felt that these pre-mixed drinks were appealing to young people because of their sweet taste, attractive packaging, low cost and targeted advertising campaigns. Evidence suggests that the alcohol industry is increasingly focussing its marketing toward adolescents and young adults with an emphasis on associating drinking and sexual, social and sporting success which conveys positive messages about alcohol consumption34-37.
Where and when alcohol is consumed: Parents identified a wide range of settings in which alcohol use/misuse occurs, for example, parties, pubs and nightclubs, friends' homes, sporting clubs, community or other public events and in the home or family setting. Adolescent drinking prior to going out was also common and attributed to cost saving. Geographical distance from a town was regarded as reducing adolescent alcohol use by restricting access to social functions where alcohol is readily available.
Perceived influences on adolescent alcohol use
Our data suggest that parents perceived that there was a wide range of factors that influence adolescents' drinking behaviours and adverse alcohol-related problems. These included parental and family relationships, peers, culture, media and school education programs, money and reasons for drinking. The strongest influences were thought by these parents, to be parental and family relationships and peers.
Parental and family relationships: Parental and family drinking was viewed by parents as a strong influence on adolescent drinking behaviour. Consistent with previous research2,6,22-24,38 parents believed that adolescents' alcohol use was principally influenced by parents through role modelling. A typical teenage attitude reported by parents about alcohol use was 'if you do it as a parent then why shouldn't we?' Parents were aware that they needed to be cautious to ensure that they did not send mixed messages about alcohol use. They thought that they would be a better role model and have a greater impact on adolescents' drinking behaviour through their own example, rather than through words.
A number of factors were seen by rural parents as strengthening the adolescent-parent relationship and impacting positively on adolescents' use of alcohol. Good communication from a young age was seen as the key to successful negotiation of adolescents' use of alcohol. This is consistent with the findings of a longitudinal study of family influences on the development of adolescent risky alcohol use39 which suggests that children who are raised in supportive, nurturing environments are more likely to be receptive to parental monitoring during the adolescent years.
A good adolescent-parent relationship was also thought to be based on trust, respect, and shared family and parental values and attitudes. This is supported by other studies which indicate that parental warmth, support, monitoring21,39-41 and tolerance38 of alcohol consumption have been identified as factors which can influence adolescent non-use/misuse of alcohol. Further to this, adolescents are more likely to legitimise parental authority regarding alcohol than they are in relation to conventional or contemporary issues20.
Some parents raised concerns about conflicting beliefs that came from parents, families of origin, school and other parents. One parent shared a story about her and her husband's differing views about the age of initiation to alcohol use in the home environment:
... the 17 and a half year old... he will have a glass of wine with us, that is fine I am quite comfortable with that... we are having a glass of wine and then my husband says do you want some? This to the 14 and a half year old, and I just went no, she is 14 and a half she is not having any ... end of discussion.
Theories of negative parenting style include parental conflict over child-rearing practices and this has been positively related to adolescent alcohol use42. However, most parents recognised that negotiating adolescent drinking was a collective decision, including both parents and the adolescent.
Conflict between other parents' beliefs and the participants' own beliefs in relation to alcohol use by adolescents was also seen as a problem. One mother told a story about how another parent had provided her 14 year-old daughter with alcohol and told her not to tell her parents. Most parents supported the view that purchasing alcohol for adolescents was a family decision.
I am very careful about buying alcohol for another person's child. I think that has to be an individual family choice. I don't think I have the right to impose my view on another family.
Conversely, adolescents whose friends' parents have similar values and beliefs were seen by the parents as an advantage in terms of setting and enforcing rules and monitoring adolescent alcohol use.
Peer influences: Parents thought peer influence was a significant contributor to adolescent alcohol use, particularly among younger adolescents. Peer influence was seen to play a substantial role through social exclusion if adolescents did not participate in peer group drinking or conversely, adolescents feeling a sense of belonging or being part of a group if they do drink. The role of peer influence identified in this study was similar to that reported by others who suggested that peer pressure is one of the main influences on adolescents' use of alcohol43,44. Emler proposed a model known as reputation enhancement theory (RET) as a way of explaining how the self is influenced by and presented to a community of peers45. RET has been shown to predict risky substance use in a range of sub-populations of teenagers46-48 by virtue of the fact that adolescents seem to identify their desired reputation, and then strategically adopt behaviours (such as licit or illicit drug use), which they see as being consistent with this.
Culture: Culture was seen to play a small but significant role in adolescent alcohol use. There was agreement among parents that drinking is part of Australian rural culture and that acceptance of adolescent drinking would be difficult to change. Parents were very concerned about the inappropriate use of alcohol in sporting clubs 'kids mix sport and alcohol because it is promoted, it is there'. One parent said '[sporting] clubs put on slabs of beer for the under seventeens'. Parents also thought these views were reflected in professional sporting clubs. While small community sporting clubs in rural Victoria often provide valued social opportunities for young people, these settings often promote a culture of heavy drinking49.
Media and school education program: Parents thought that the media and school education programs have minimal impact in terms of promoting harm reduction approaches to alcohol consumption among adolescents. However, media has a dual role with advertising presenting very powerful images36. Many parents reported that they were not aware of the current Australian National Alcohol Campaign television advertisements about adolescent drinking and were not sure if their children had seen them. Those parents who did recall the advertisements thought that they could educate both adolescents and parents and they had discussed them with their children. These parents perceived the advertisements to be 'graphic' and have 'shock value'.
Consistent with current literature, school-based education programs were not seen by parents as very effective strategies for educating adolescents about alcohol use50,51. Parents believed that adolescents tend to disregard them and see them as boring. Despite this, parents did believe that the information was being taken on board by adolescents.
I don't know how the message should be better got across because I don't actually think that it is from lack of knowledge: they know. But it is actually translating it into their own personal risk is the challenge.
Although the parents indicated that they are aware that knowledge does not always translate into behavioural change, nearly all of the parents believed that alcohol education programs need to commence earlier, prior to adolescence, be more interactive and that school-based alcohol education should be compulsory. This belief may be a product of parents' need for advice and assistance on how to positively enforce safe drinking behaviours2,26 and their perceived sense of isolation and powerlessness25 to do anything about adolescent alcohol consumption. While many parents may be aware of drug and alcohol education programs in schools, they may not be cognisant that such programs are diverse in their approach, content and effectiveness52.
Money: No parent indicated that they thought cost was a barrier to adolescents consuming alcohol. This is supported by Oh and colleagues19 who found that 39% of both metropolitan and rural adolescents aged 13-17 years of age spend 37% of their weekly income on alcohol. Additionally, most parents believed that the types of alcohol adolescents choose to drink, such as pre-mixed drinks, were inexpensive relative to teenager's spending capacity.
Reasons for drinking: Parents consistently identified recreation and socialisation as the main reasons why they think adolescents drink alcohol. Parents thought that alcohol was a 'social lubricant' and that consumption is seen as socially desirable behaviour by adolescents. A concern highlighted by parents was that adolescents appeared to be drinking for no particular reason other than it being a Saturday night. This is supported by other researchers53 who found that drinking is so normal among adolescents that decisions about drinking are made without deliberate planning. It may be that parents perceive that drinking as a 'social lubricant' is acceptable among adults but not so among adolescents.
Short and long-term risks associated with adolescent alcohol use
Parents felt that adolescents perceive themselves to be 'invincible', think that 'it won't happen to me' and see drinking as 'a big game'. Additionally, parents suggested that adolescents are not aware of their own limitations and do not 'personalise' the risks of alcohol use. Further to this, parents' experiences suggest that adolescents hide their own and their friends' intoxication, and that risk-taking behaviour tends to occur in groups, not individually.
Parents perceived alcohol as less dangerous than other drugs and many commented that alcohol was not viewed as a drug by some parents and adolescents. This is consistent with previous reports25 and probably reflects alcohol's legal status and high levels of acceptance in society generally.
The risks or harms associated with adolescents' use of alcohol perceived by parents were both short and long-term. However, most parents seemed more concerned about the more immediate short-term risks such as the physical dangers as a result of drunkenness. These included injuries (including assault), accidents, aspiration of vomit, unconsciousness, drowning, sequelae of unsafe sex, drink spiking, loss of control and death. While parents expressed major concerns about these consequences, they did not identify sequelae related to excessive alcohol consumption that have been described in the literature36, such as decreased scholastic and sporting performance, aggression, violence, disrupted family relationships, drink driving and delinquent behaviour. It appears that parents are more concerned with harms that are acute with visible severe consequences.
The long-term risks were of less concern to most parents who thought adolescents were unconcerned about potential long-term risks to their health such as permanent injuries or impaired development. As one parent said 'no, they [adolescents] wouldn't care, that wouldn't worry them in the slightest'. The main long-term risks or harms parents were concerned about included head injuries causing permanent damage, relationship problems, adolescents' tolerance of alcohol and alcohol use affecting their development. Parents appeared to have a limited knowledge of the long-term risks associated with chronic alcohol use. This is consistent with their expressed view of a lack of information about the long-term consequences. Some parents believed the health benefits of moderate alcohol use outweigh the risks. While there is evidence that the initial effects of alcohol may reduce tension and induce relaxation, increasing levels of alcohol reduces cognitive and psycho-motor performance7.
Parents' harm-reduction strategies and access to information
Access to alcohol in the home: A number of parents had offered alcohol to their adolescents during a family meal or at a family special occasion and believed this was teaching safe drinking practices. Previous evidence indicates, however, that pre-adolescent children who were permitted to drink alcohol at home under their parents' supervision have more than twice the odds of reporting subsequent alcohol use54,55. So, prohibiting alcohol use in the home may reduce the likelihood of early adolescent use and, indeed, misuse of alcohol. Early access to alcohol has also been associated with subsequent elevated levels of alcohol use, early binge drinking and social problems associated with problem drinking5,6,55. Despite this evidence, the introduction of alcohol by parents to children seems to have good face validity for parents and any attempt to prohibit pre-adolescent drinking in the home may appear to be a threat to parental autonomy and hence met with resistance.
Parental purchasing of alcohol: Physical access to alcohol was not identified by parents as a barrier for adolescents. Alcohol was purchased for adolescents by parents, friends' parents or siblings, peers, or taxi drivers. Sometimes adolescents took alcohol from home or purchased their own. The purchase of alcohol by parents was common and some parents believed this could reduce harm by controlling how much their children drank. 'If you don't buy it for them they are going to get it anyway and they will probably get twice as much'. This contrasts with evidence which suggests that parents who buy and supply adolescents with alcohol are contributing to the increased risk of adolescents engaging in binge drinking and consuming more alcohol on a given occasion56. Consistent with existing evidence, some parents thought that adolescents will consume what has been provided by their parents, plus more which they may access by recruiting strangers (eg taxi drivers) to purchase for them. It might be that parents who purchase alcohol for their children normalised teenage alcohol consumption and removed one of the constraints on young people's behaviour.
Abstinence: Some parents reported that their children's schools had a complete abstinence policy regarding adolescent drinking, which conflicted with their own values and created difficulties in providing a consistent message for their offspring. Those parents felt that regardless of rule setting on abstinence, adolescents will try alcohol. However, abstinence does have a place as a harm-reduction strategy in an overall harm minimisation policy - it is not exclusive to zero tolerance, and this fact is frequently overlooked.
Other strategies: Parents utilise a number of strategies to reduce the harm associated with adolescent alcohol use. Some parents provided their adolescents with a mobile phone and felt that transporting their teenagers was a good way to monitor alcohol use. However, it was the experience of some parents that girls were provided with transport and not boys. Some parents felt that not allowing their adolescents to sleep-over at a friend's house was a good strategy to reduce risks and monitor alcohol use. Many participants reported telephoning parents who were holding a party. Parents asked questions such as 'Is there going to be alcohol?' and 'Will other parents attend?' However, the experience of the parents was that not many other parents do telephone. 'A number of times when I have rang [the parents] have said I am glad you rang but there has been only [been] one other [parent] ring'.
There was agreement among parents that adolescents respected designated driver programs and believed that 'they [adolescents] never drink and drive'. Most parents believed that turning 18 years old and getting a car licence curbs the use of alcohol. Despite these reports, young people are still over-represented in the rural road trauma statistics. In 2003, those under 25 years of age comprised the largest group of road users involved in crashes in rural Victoria57.
Teaching adolescents strategies for safe drinking practice including education about drink spiking and 'moderate' use of alcohol were important to most parents. These strategies were combined by most parents and formed a safety plan that they negotiated with their adolescents. These practices are consistent with Australia's National Alcohol Strategy1.
Information: For parents to be able to play an effective role in the prevention of adolescents' alcohol use, they need information and support. The main sources of information and support reported by parents were peers, their own experience, schools, seminars and education programs for adolescents, the media and printed materials. 'I get my information from other parents... [I] just try to have a little bit of common sense'. Some parents said that they 'might just pick up a drug leaflet somewhere'. Most parents indicated that their children's schools conducted information evenings for parents about alcohol and other drugs and thought these sessions were informative and useful.
Some parents identified a need for support, information and strategies for dealing with adolescents' alcohol use. Parents think information that is currently available is not sufficient and does not provide enough practical advice. Parents from rural areas are often socially and geographically isolated and lack opportunities to access the more expansive support and information sources available to town and city dwellers.
While this study has provided more detailed information of parents' experiences and perceptions of young people's drinking, and their knowledge, attitudes and beliefs, the findings must be viewed with caution. One of the limitations of this study was the sampling method used. Non-probability convenience and snowball sampling lead to self-selection bias and thus the sample may not be representative of the population of interest. Parents who chose to participate are likely to be different from those parents who did not choose to participate in this study. Thus, it is possible that these parents' views may be somewhat atypical of parents of rural teenagers' views generally.
Parents in this study perceived that rural adolescents drink alcohol to get drunk quickly and that teenage levels of drinking are strongly influenced by their own parental role modelling and that of their adolescent peers. Harm reduction strategies were identified as being important to parents and there was a strong emphasis on short-term risks associated with risky levels of alcohol consumption among adolescents. Currently, some parental strategies may have good face validity in reducing alcohol consumption among adolescents, while in fact being counter-productive by normalising the use of alcohol and contributing to ongoing harm. These approaches may be associated with parental lack of knowledge about the long-term risks of alcohol, and the need for more support and information so that parents can confidently make informed decisions in guiding their adolescents' use of alcohol and access to alcohol at public and private venues.
The findings suggest that rural parents struggle to know how to respond to their adolescents' alcohol use and drunkenness. Parental fears about teenagers' risk of exposure to danger while intoxicated are clear; however, what is not clear for these parents is what is 'normal' and what is 'problematic' alcohol use and, therefore, how they should respond to alcohol use. Parents appear to face a dilemma as to whether they should be disciplinary or take the role of a supportive teacher when it comes to their teenagers' use of alcohol. Parents are required to make these challenging and difficult decisions often without the knowledge or support they need. It seems that parenting style is more orientated to reacting to specific scenarios and that parents are unclear how to proactively influence their teenagers' alcohol use. This suggests that alcohol education programs directed towards parents would be valuable to assist parents make these difficult decisions and provide guidance as to how they can best educate their teenagers.
Further research is needed to determine the implications of these findings in the area of policy, education, liquor licensing and law enforcement. A metropolitan study is currently being conducted which will assist to explore the extent to which these experiences and concerns exist regardless of geographical context.
We would like to thank the school principals and parents who supported and participated in the project. We would also like to thank the Workforce Section of the Commonwealth Department of Health and Aged Care for funding the Victorian University Rural Health Consortium who provided the resources to conduct this project.
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