Original article
Prevalence and risk indicators of alcohol abuse and marijuana use among on-reserve First Nations youth Mark Lemstra PhD, Marla Rogers MPA, John Moraros MD PhD, Sam Caldbick MPH M Lemstra, M Rogers, J Moraros, s Caldbick. Prevalence and risk indicators of alcohol abuse and marijuana use among on-reserve First Nations youth. Paediatr Child health 2013;18(1):10-14. The objectives of the present study were to identify the prevalence of alcohol abuse and marijuana use among First Nations youth living onreserve, and to identify independent risk indicators associated with these behaviours. Two hundred four students from the Saskatoon Tribal Council (Saskatchewan) who were enrolled in grades 5 through 8 were asked to complete a school health survey. The prevalence of alcohol abuse and marijuana use among First Nations onreserve youth was 23.5% and 14.7%, respectively. Surprisingly, female First Nations youth were more likely to abuse alcohol and use marijuana than male First Nations youth. The prevalence of alcohol abuse and marijuana use among Saskatoon urban youth of the same age were only 5.4% and 2.7%, respectively. After regression analysis, five independent risk indicators were associated with alcohol abuse and marijuana use among First Nations on-reserve youth. The prevalence of alcohol abuse among First Nations on-reserve youth is higher than that in neighbouring urban youth of the same age. Key Words: Alcohol abuse; Marijuana use; Minority groups; Risk factors;
Youth
E
arly onset of alcohol abuse and marijuana use has been associated with an increased use of other drugs later in adolescence and adulthood, as well as increases in the incidence of recreational accidents, sexual intercourse, teenage pregnancy and poorer academic performance (1-8). According to one study regarding youth risk behaviours in the United States (9), the prevalence of alcohol abuse among Aboriginal youth in grades 9 through 12 was 49.4% for boys and 35.7% for girls. In comparison, 38.6% of male and 21.9% of female Caucasian youth abused alcohol. Marijuana use among Aboriginal youth was also higher. In the same study, 47.5% of male and 48.5% of female Aboriginal youth were found to use marijuana in comparison with 29.1% of male and 24.2% of female Caucasian youth. A study conducted in Manitoba on youths in grades 5 through 12 (10) compared the prevalence of alcohol abuse and marijuana use among Aboriginal youth living off reserve with non-Aboriginal youth. The study found that 61% of Aboriginal youth compared with 54% of non-Aboriginal youth reported use of alcohol. Additionally, the prevalence of marijuana use was 30% in Aboriginal youth and 8% among non-Aboriginal youth. A study performed in Saskatoon, Saskatchewan, involving youth 10 to 15 years of age (11), reported the prevalence of alcohol abuse and marijuana use in urban Aboriginal (First Nations, Métis) youth and non-Aboriginal youth. The prevalence of alcohol abuse and marijuana use in Aboriginal youth was 16.7% and 21.5%,
La prévalence et les indicateurs de risque de consommation excessive d’alcool et de consommation de marijuana chez les jeunes des Premières nations qui habitent dans les réserves La présente étude visait à déterminer la prévalence de consommation excessive d’alcool et de consommation de marijuana chez les jeunes des Premières nations qui habitent dans les réserves, ainsi que les indicateurs de risque indépendants associés à ces comportements. Deux cent quatre élèves de cinquième à huitième année du Conseil de bande de Saskatoon, au Canada, ont été invités à répondre à un sondage sur la santé en milieu scolaire. La prévalence de consommation abusive d’alcool et de consommation de marijuana chez les jeunes des Premières nations dans les réserves s’élevait à 23,5 % et 14,7 %, respectivement. Fait surprenant, les jeunes filles de ce groupe étaient plus susceptibles de consommer trop d’alcool et de consommer de la marijuana que les jeunes garçons. La prévalence de consommation excessive d’alcool et de consommation de marijuana chez les jeunes en milieu urbain de Saskatoon ne s’élevait qu’à 5,4 % et 2,7 %, respectivement. Après l’analyse de régression, cinq indicateurs de risque indépendants s’associaient à la consommation excessive d’alcool et à la consommation de marijuana chez les jeunes des Premières nations dans les réserves, dont la prévalence de consommation excessive d’alcool est plus élevée que celle des jeunes du même âge d’un milieu urbain voisin.
respectively. Non-Aboriginal youth reported lower prevalences of alcohol abuse and marijuana use at 5.4% and 2.7%, respectively. The First Nations Regional Longitudinal Health Survey from 2002/2003 indicated that 42.2% of First Nations youth 13 to 17 years of age had answered that they had consumed at least one alcoholic beverage in the previous year and that 32.7% reported using marijuana in 2003. However, these data were not collected with a validated survey and do not capture earlier onset of use (12). A review of the literature for studies determining the prevalence of, or independent risk factors for, alcohol abuse or marijuana use among First Nations youth living on-reserve in Canada was unsuccessful. Therefore, the first objective of the present study was to determine the prevalence of alcohol abuse and marijuana use in Saskatoon Tribal Council (STC) First Nations youth living on reserve. The second objective was to identify the independent risk indicators for alcohol abuse and marijuana use among on-reserve First Nations youth.
Methods
The STC consists of seven First Nations reserves within a 250 km radius around Saskatoon. Within the STC, according to the 2006 census (13), the median annual income per household was $8,572, the high school graduation rate was 50.7%, and the male and female adult unemployment rates were 27.5% and 20.7%,
University of Saskatchewan, School of Public Health, Saskatoon, Saskatchewan Correspondence: Mrs Marla Rogers, University of Saskatchewan, School of Public Health, Health Sciences Building, 107 Wiggins Road, Saskatoon, Saskatchewan S7N 5E5. Telephone 306-655-8662, e-mail [email protected] Accepted for publication March 23, 2012
10
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 1 January 2013
Alcohol and marijuana use among on-reserve First Nations youth
respectively. In comparison, the median annual income per household was $23,755, the high school graduation rate was 80.6% and the male and female adult unemployment rates were 5.9% and 5.3%, respectively, among the Saskatchewan adult population (13). Students in grades 5 through 8 (10 to 16 years of age) within the STC were asked to complete a health survey in May 2010. Within these grades among the seven schools, 271 students were eligible to participate. Before initiating the study, 41 community consultations occurred with Chiefs, Elders, Band Councillors, Health Directors, the Education Director, principals, teachers, parents, children and community members. An eight-stage consent protocol was followed, which consisted of collecting written consent from the Chiefs, Band Councillors and Health Directors from each of the First Nation communities, as well as from the Education Director. The principal of each school and the teacher of each classroom were required to give verbal consent. Parents or caregivers and each youth participant were required to give written, informed consent before the youth’s participation. The ethics submission included signatures from the Director of Research, the Director of Health and the Director of Education from the STC. The principal investigator was the Director of Research from the STC. Tri-Council guidelines and the principles of ownership, possession, access and control were followed. On completion, a Chiefs Resolution and seven Band Council Resolutions were obtained for the project to proceed. Ethics approval was obtained from the University of Saskatchewan (Saskatoon, Saskatchewan) Behavioural Research Ethics Board (BEH#10-14). Youth were considered to have abused alcohol if they answered yes to the question: “Have you ever been drunk?”. Marijuana use was defined as someone who responded yes to the question: “Have you used marijuana in the past 12 months?”. Both questions were taken from Statistics Canada’s Youth Smoking Survey (YSS). This survey has been used since 1994 but has excluded First Nations youth living on reserve (14). These questions from the YSS have been evaluated for external validity with the National Population Health Survey, as well as the Canadian Tobacco Use Monitoring Survey, with similar results found despite differences in methodology (15). Both questions on alcohol abuse and marijuana use have been validated and published previously in another article on urban Saskatoon youth (11). Questions on demographics and socioeconomic status (SES) were taken from Statistics Canada’s National Longitudinal Survey of Children and Youth (NLSCY). This comprehensive health survey was designed to collect information about factors that influence a youth’s social, emotional and behavioural development. The NLSCY has been validated for youth 10 to 13 years of age (16). Parenting questions came from the Parenting Relationship Scale that was used in the Health Behaviour in School-Aged Children study (17). Although validity and reliability data have never been published, the scale has been used in an international project facilitated by the WHO. The questions on suicide ideation, self-esteem, self-reported health and mental health were also taken from the NLSCY (16). Questions for the self-esteem scale used in the NLSCY are derived from the Marsh Self Description Questionnaire, which has a coefficient alpha reliability range of 0.80 to 0.94 (18,19). The instrument used to measure depressed mood was the Center for Epidemiological Studies Depression scale (20). This scale was used on youth in the NLSCY and has a Cronbach’s alpha of 0.85 (21,22). A cut-off score of 16 or higher was used as the cutoff for depressed mood. Paediatr Child Health Vol 18 No 1 January 2013
Current smoking status for the present study was defined as someone who has smoked one or more entire cigarette(s) within the past 30 days and was also taken from the YSS. The definition of smoking status used in the present study is complementary to Health Canada’s criteria on phases of smoking uptake (23). Cross tabulations were performed between alcohol abuse, as well as marijuana use, and all measured variables. After these cross tabulations, binary logistic regression was used to determine the independent association between the outcome variable of abusing alcohol (in comparison with not) and using marijuana (in comparison with not) and the potential explanatory variables. The unadjusted effect of each covariate was determined and subsequently entered one step at a time based on changes in the −2 log likelihood and the Wald test (24). The final results were presented as adjusted ORs with 95% CIs. On completion of the study, 11 knowledge transfer sessions were conducted. Future knowledge translation will be at the discretion of the Tribal Chief. The principles of ownership, possession, access and control were followed. The Tribal Chief was given a full copy of the de-identified data set. The STC Tribal Chief, Director of Research, Director of Health, Director of Education and Manager of Mental Health, among others, reviewed the manuscript before submission. No ethical violations were noted during or after the research study. The Behavioural Research Ethics Board at the University of Saskatchewn closed the file on completion of study without incident.
ResuLts
In total, 204 (75.8%) on-reserve First Nations youth completed the survey. According to the 2006 census, there were 239 known STC youth 10 to 17 years of age living on reserve (25). Because the present sample (204 youth, 10 to 16 years of age) is in accord with what was reported in the 2006 census, it is believed that the sample is representative of the communities. Overall, 10.3% of the youths were 10 years of age, 48% were 11 to 12 years of age, and 40.2% were 13 to 16 years of age. Males comprised 44.1% of the sample. The majority (55.9%) had a father who was employed, with 92.6% working in a nonprofessional occupation (nonmanagement or an occupation that does not require a degree). In addition, 46.1% of the participants had a mother who was employed, with 73.6% of those employed working in a nonprofessional occupation (26). The prevalence of alcohol abuse and marijuana use among STC youth was 23.5% and 14.7%, respectively. Both alcohol abuse and marijuana use were initially associated with higher school grade, older age and female sex. For example, 35.8% of female students reported alcohol abuse compared with 12.3% of male students, and 21.2% of female students reported marijuana use compared with 11.4% of male students. As well, 59.4% of grade 8 students abused alcohol compared with 35.9% of grade 7 students, 13% of grade 6 students and 13.8% of grade 5 students (Table 1). Parenting variables that were initially significantly associated with both alcohol abuse and marijuana use included disagreeing that their parents understand them, not having a happy home life, disagreeing that their parents trust them, wanting to leave home and not caring what their parents think of them. For example, 52.3% of youth that did not have a happy home life reported alcohol abuse in comparison with 17.9% who did. Engaging in many arguments with parents was significantly associated with marijuana use but not with alcohol abuse (Table 2). Depressed mood, suicide ideation and lower self-reported mental health were associated with both alcohol abuse and marijuana use. Lower self-reported health was associated with marijuana use 11
Lemstra et al
TAbLe 1 Cross tabulations of demographic and socioeconomic variables with alcohol abuse and marijuana use among Saskatoon Tribal Council on-reserve First Nations youth Alcohol abuse, % School grade
P
Marijuana use, %
Prevalence and risk indicators of alcohol abuse and marijuana use among on-reserve First Nations youth Mark Lemstra PhD, Marla Rogers MPA, John Moraros MD PhD, Sam Caldbick MPH M Lemstra, M Rogers, J Moraros, s Caldbick. Prevalence and risk indicators of alcohol abuse and marijuana use among on-reserve First Nations youth. Paediatr Child health 2013;18(1):10-14. The objectives of the present study were to identify the prevalence of alcohol abuse and marijuana use among First Nations youth living onreserve, and to identify independent risk indicators associated with these behaviours. Two hundred four students from the Saskatoon Tribal Council (Saskatchewan) who were enrolled in grades 5 through 8 were asked to complete a school health survey. The prevalence of alcohol abuse and marijuana use among First Nations onreserve youth was 23.5% and 14.7%, respectively. Surprisingly, female First Nations youth were more likely to abuse alcohol and use marijuana than male First Nations youth. The prevalence of alcohol abuse and marijuana use among Saskatoon urban youth of the same age were only 5.4% and 2.7%, respectively. After regression analysis, five independent risk indicators were associated with alcohol abuse and marijuana use among First Nations on-reserve youth. The prevalence of alcohol abuse among First Nations on-reserve youth is higher than that in neighbouring urban youth of the same age. Key Words: Alcohol abuse; Marijuana use; Minority groups; Risk factors;
Youth
E
arly onset of alcohol abuse and marijuana use has been associated with an increased use of other drugs later in adolescence and adulthood, as well as increases in the incidence of recreational accidents, sexual intercourse, teenage pregnancy and poorer academic performance (1-8). According to one study regarding youth risk behaviours in the United States (9), the prevalence of alcohol abuse among Aboriginal youth in grades 9 through 12 was 49.4% for boys and 35.7% for girls. In comparison, 38.6% of male and 21.9% of female Caucasian youth abused alcohol. Marijuana use among Aboriginal youth was also higher. In the same study, 47.5% of male and 48.5% of female Aboriginal youth were found to use marijuana in comparison with 29.1% of male and 24.2% of female Caucasian youth. A study conducted in Manitoba on youths in grades 5 through 12 (10) compared the prevalence of alcohol abuse and marijuana use among Aboriginal youth living off reserve with non-Aboriginal youth. The study found that 61% of Aboriginal youth compared with 54% of non-Aboriginal youth reported use of alcohol. Additionally, the prevalence of marijuana use was 30% in Aboriginal youth and 8% among non-Aboriginal youth. A study performed in Saskatoon, Saskatchewan, involving youth 10 to 15 years of age (11), reported the prevalence of alcohol abuse and marijuana use in urban Aboriginal (First Nations, Métis) youth and non-Aboriginal youth. The prevalence of alcohol abuse and marijuana use in Aboriginal youth was 16.7% and 21.5%,
La prévalence et les indicateurs de risque de consommation excessive d’alcool et de consommation de marijuana chez les jeunes des Premières nations qui habitent dans les réserves La présente étude visait à déterminer la prévalence de consommation excessive d’alcool et de consommation de marijuana chez les jeunes des Premières nations qui habitent dans les réserves, ainsi que les indicateurs de risque indépendants associés à ces comportements. Deux cent quatre élèves de cinquième à huitième année du Conseil de bande de Saskatoon, au Canada, ont été invités à répondre à un sondage sur la santé en milieu scolaire. La prévalence de consommation abusive d’alcool et de consommation de marijuana chez les jeunes des Premières nations dans les réserves s’élevait à 23,5 % et 14,7 %, respectivement. Fait surprenant, les jeunes filles de ce groupe étaient plus susceptibles de consommer trop d’alcool et de consommer de la marijuana que les jeunes garçons. La prévalence de consommation excessive d’alcool et de consommation de marijuana chez les jeunes en milieu urbain de Saskatoon ne s’élevait qu’à 5,4 % et 2,7 %, respectivement. Après l’analyse de régression, cinq indicateurs de risque indépendants s’associaient à la consommation excessive d’alcool et à la consommation de marijuana chez les jeunes des Premières nations dans les réserves, dont la prévalence de consommation excessive d’alcool est plus élevée que celle des jeunes du même âge d’un milieu urbain voisin.
respectively. Non-Aboriginal youth reported lower prevalences of alcohol abuse and marijuana use at 5.4% and 2.7%, respectively. The First Nations Regional Longitudinal Health Survey from 2002/2003 indicated that 42.2% of First Nations youth 13 to 17 years of age had answered that they had consumed at least one alcoholic beverage in the previous year and that 32.7% reported using marijuana in 2003. However, these data were not collected with a validated survey and do not capture earlier onset of use (12). A review of the literature for studies determining the prevalence of, or independent risk factors for, alcohol abuse or marijuana use among First Nations youth living on-reserve in Canada was unsuccessful. Therefore, the first objective of the present study was to determine the prevalence of alcohol abuse and marijuana use in Saskatoon Tribal Council (STC) First Nations youth living on reserve. The second objective was to identify the independent risk indicators for alcohol abuse and marijuana use among on-reserve First Nations youth.
Methods
The STC consists of seven First Nations reserves within a 250 km radius around Saskatoon. Within the STC, according to the 2006 census (13), the median annual income per household was $8,572, the high school graduation rate was 50.7%, and the male and female adult unemployment rates were 27.5% and 20.7%,
University of Saskatchewan, School of Public Health, Saskatoon, Saskatchewan Correspondence: Mrs Marla Rogers, University of Saskatchewan, School of Public Health, Health Sciences Building, 107 Wiggins Road, Saskatoon, Saskatchewan S7N 5E5. Telephone 306-655-8662, e-mail [email protected] Accepted for publication March 23, 2012
10
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 1 January 2013
Alcohol and marijuana use among on-reserve First Nations youth
respectively. In comparison, the median annual income per household was $23,755, the high school graduation rate was 80.6% and the male and female adult unemployment rates were 5.9% and 5.3%, respectively, among the Saskatchewan adult population (13). Students in grades 5 through 8 (10 to 16 years of age) within the STC were asked to complete a health survey in May 2010. Within these grades among the seven schools, 271 students were eligible to participate. Before initiating the study, 41 community consultations occurred with Chiefs, Elders, Band Councillors, Health Directors, the Education Director, principals, teachers, parents, children and community members. An eight-stage consent protocol was followed, which consisted of collecting written consent from the Chiefs, Band Councillors and Health Directors from each of the First Nation communities, as well as from the Education Director. The principal of each school and the teacher of each classroom were required to give verbal consent. Parents or caregivers and each youth participant were required to give written, informed consent before the youth’s participation. The ethics submission included signatures from the Director of Research, the Director of Health and the Director of Education from the STC. The principal investigator was the Director of Research from the STC. Tri-Council guidelines and the principles of ownership, possession, access and control were followed. On completion, a Chiefs Resolution and seven Band Council Resolutions were obtained for the project to proceed. Ethics approval was obtained from the University of Saskatchewan (Saskatoon, Saskatchewan) Behavioural Research Ethics Board (BEH#10-14). Youth were considered to have abused alcohol if they answered yes to the question: “Have you ever been drunk?”. Marijuana use was defined as someone who responded yes to the question: “Have you used marijuana in the past 12 months?”. Both questions were taken from Statistics Canada’s Youth Smoking Survey (YSS). This survey has been used since 1994 but has excluded First Nations youth living on reserve (14). These questions from the YSS have been evaluated for external validity with the National Population Health Survey, as well as the Canadian Tobacco Use Monitoring Survey, with similar results found despite differences in methodology (15). Both questions on alcohol abuse and marijuana use have been validated and published previously in another article on urban Saskatoon youth (11). Questions on demographics and socioeconomic status (SES) were taken from Statistics Canada’s National Longitudinal Survey of Children and Youth (NLSCY). This comprehensive health survey was designed to collect information about factors that influence a youth’s social, emotional and behavioural development. The NLSCY has been validated for youth 10 to 13 years of age (16). Parenting questions came from the Parenting Relationship Scale that was used in the Health Behaviour in School-Aged Children study (17). Although validity and reliability data have never been published, the scale has been used in an international project facilitated by the WHO. The questions on suicide ideation, self-esteem, self-reported health and mental health were also taken from the NLSCY (16). Questions for the self-esteem scale used in the NLSCY are derived from the Marsh Self Description Questionnaire, which has a coefficient alpha reliability range of 0.80 to 0.94 (18,19). The instrument used to measure depressed mood was the Center for Epidemiological Studies Depression scale (20). This scale was used on youth in the NLSCY and has a Cronbach’s alpha of 0.85 (21,22). A cut-off score of 16 or higher was used as the cutoff for depressed mood. Paediatr Child Health Vol 18 No 1 January 2013
Current smoking status for the present study was defined as someone who has smoked one or more entire cigarette(s) within the past 30 days and was also taken from the YSS. The definition of smoking status used in the present study is complementary to Health Canada’s criteria on phases of smoking uptake (23). Cross tabulations were performed between alcohol abuse, as well as marijuana use, and all measured variables. After these cross tabulations, binary logistic regression was used to determine the independent association between the outcome variable of abusing alcohol (in comparison with not) and using marijuana (in comparison with not) and the potential explanatory variables. The unadjusted effect of each covariate was determined and subsequently entered one step at a time based on changes in the −2 log likelihood and the Wald test (24). The final results were presented as adjusted ORs with 95% CIs. On completion of the study, 11 knowledge transfer sessions were conducted. Future knowledge translation will be at the discretion of the Tribal Chief. The principles of ownership, possession, access and control were followed. The Tribal Chief was given a full copy of the de-identified data set. The STC Tribal Chief, Director of Research, Director of Health, Director of Education and Manager of Mental Health, among others, reviewed the manuscript before submission. No ethical violations were noted during or after the research study. The Behavioural Research Ethics Board at the University of Saskatchewn closed the file on completion of study without incident.
ResuLts
In total, 204 (75.8%) on-reserve First Nations youth completed the survey. According to the 2006 census, there were 239 known STC youth 10 to 17 years of age living on reserve (25). Because the present sample (204 youth, 10 to 16 years of age) is in accord with what was reported in the 2006 census, it is believed that the sample is representative of the communities. Overall, 10.3% of the youths were 10 years of age, 48% were 11 to 12 years of age, and 40.2% were 13 to 16 years of age. Males comprised 44.1% of the sample. The majority (55.9%) had a father who was employed, with 92.6% working in a nonprofessional occupation (nonmanagement or an occupation that does not require a degree). In addition, 46.1% of the participants had a mother who was employed, with 73.6% of those employed working in a nonprofessional occupation (26). The prevalence of alcohol abuse and marijuana use among STC youth was 23.5% and 14.7%, respectively. Both alcohol abuse and marijuana use were initially associated with higher school grade, older age and female sex. For example, 35.8% of female students reported alcohol abuse compared with 12.3% of male students, and 21.2% of female students reported marijuana use compared with 11.4% of male students. As well, 59.4% of grade 8 students abused alcohol compared with 35.9% of grade 7 students, 13% of grade 6 students and 13.8% of grade 5 students (Table 1). Parenting variables that were initially significantly associated with both alcohol abuse and marijuana use included disagreeing that their parents understand them, not having a happy home life, disagreeing that their parents trust them, wanting to leave home and not caring what their parents think of them. For example, 52.3% of youth that did not have a happy home life reported alcohol abuse in comparison with 17.9% who did. Engaging in many arguments with parents was significantly associated with marijuana use but not with alcohol abuse (Table 2). Depressed mood, suicide ideation and lower self-reported mental health were associated with both alcohol abuse and marijuana use. Lower self-reported health was associated with marijuana use 11
Lemstra et al
TAbLe 1 Cross tabulations of demographic and socioeconomic variables with alcohol abuse and marijuana use among Saskatoon Tribal Council on-reserve First Nations youth Alcohol abuse, % School grade
P
Marijuana use, %
