Rurality and Gender Effects
on
Early Adolescent Alcohol
Use
Kelly J. Kelleher, MD, MPH; Vaughn I. Rickert, PsyD; Brian H. Hardin, MD; Sandra K. Pope, MPH; Frank L. Farmer, PhD studies of adolescent alcohol use have focused almost exclusively on urban and suburban youth, although alcohol is the most important drug of abuse among rural adolescents. Young adolescents, aged 11 to 14 years (N=1601), from urban, suburban, and two different rural areas (delta and highland), were surveyed about health\x=req-\ compromising behaviors, such as alcohol use. Significant differences in the number of adolescents using alcohol and the patterns of alcohol use were noted across areas by gender. Youths from the delta area, especially girls, reported drinking less frequently and in less abusive patterns than did adolescents from other areas, while youths from the highland area reported rates and patterns of drinking similar to those of urban adolescents. The reasons for intrarural variation in adolescent drinking are unknown.
\s=b\ Previous
(AJDC. 1992;146:317-322)
is an issue in the and in various pop¬ ulations to have higher rates of alcohol abuse, alcohol de¬ pendence, and problem drinking than urban populations. A recent government study concluded that, in the rural sector, alcohol is the most important drug of abuse. Na¬ tional statistics reaffirm this conclusion; predominantly rural states have higher rates of alcohol-related arrests, admissions to hospitals for treatment of alcohol abuse, and unintentional injuries associated with alcohol use compared with predominantly metropolitan states.6 Preliminary studies suggest that rural teenagers are similar to rural adults in that alcohol is the most frequent drug of abuse. High school seniors from rural areas are more likely than metropolitan seniors to report daily use of alcohol.7 Three predominantly rural states, Iowa, Montana, and North Dakota, report higher lifetime and 30-day alcohol use rates among high school seniors than the national averages.6 Among young adolescents, stud-
important health and mental health Alcohol abuse rural United States. Research conducted countries3"5 has shown rural states1-2
Accepted for publication October 8, 1991. From the Departments of Pediatrics (Drs Kelleher, Rickert, Hardin, and Pope) and Psychiatry (Dr Kelleher), University of Arkansas for Medical Sciences, Little Rock, and the Departments of Agricultural Economics and Rural Sociology (Dr Farmer), University of Arkansas, Fayetteville. Reprint requests
to
Department of Pediatrics,
Little Rock, AR 72202 (Dr Kelleher).
800 Marshall
St,
ies of a limited number of rural schools8-9 identified much higher rates of drinking and problem drinking than would be expected from national surveys. While these earlier studies are suggestive, there are very few empirically based studies that focus strictly on the prevalence of drinking among rural adolescents or the associated risk factors and patterns of alcçhol use. In general, published studies have been compromised by small sample sizes and by the use of single school sites and unstandardized measures. As a result, clear implica¬ tions for the development of treatment and prevention models for rural adolescents have not been presented.10 Nevertheless, some evidence exists to infer that preva¬ lence estimates and etiologic models of adolescent drink¬ ing from studies of urban and suburban populations may not be applicable to rural adolescents. In particular, many of the environmental factors related to alcohol use in adolescence identified in previous research may be quite different for rural teenagers. Con¬ textual variables such as parental supervision and partic¬ ular social events may be critical in determining patterns of use,1113 and these factors are likely to be different be¬ tween rural and urban communities.14 Hassinger1^ and Rogers and Burdge16 suggest that rural areas are more conservative, religious, unified, and family-centered than urban areas. How these characteristics, combined with the geographic isolation, poverty, transportation difficul¬ ties, and the unstable economy faced by many rural youth,17 impact drinking practices is unknown. However, they clearly represent a fundamentally different context for risk. Rural adolescents are an important population to study for a number of other reasons. Almost one third of all ad¬ olescents and children reside in rural areas.18 Rural ado¬ lescents are more likely to be poor and live in substandard housing than metropolitan teenagers.18 They are less likely to have health insurance and access to medical and mental health care.17 As with other youths, the vast major¬ ity of morbidity and mortality among rural adolescents is related to health-compromising behaviors,618 including alcohol use and problem drinking. The origins and risk factors related to alcohol use in rural adolescents are
poorly understood. This study was undertaken to provide insight into dif¬ ferences in the prevalence of alcohol use and patterns of drinking in rural and urban contexts as well as to assess
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/12/2015
the other variables associated with early adolescent drink¬ ing. While preliminary expectations were that urban and suburban areas would have similar prevalence rates and similar psychosocial and demographic correlates, we an¬ different rates and patterns of drinking in rural areas (greater amount consumed per occasion, but fewer occasions).9 Further, recognizing the inherent heteroge¬ neity in social and geographic conditions in rural areas, we explored the prevalence and patterns of drinking in different rural settings.
ticipated
SUBJECTS AND METHODS
Study Design
Four areas representing the diverse geography of Arkansas were studied. The urban area was a metropolitan district in which most children attended public schools. Approximately 50% of the population was black. The suburban area had a largely white population, and more children in this area at¬ tended private schools than did children in the metropolitan area. The rural area of the Ozark highlands that was selected for the study was characterized by its poultry industry and tourism and was homogeneous in racial composition (white). The fourth area, the lower Mississippi Delta region, was characterized by row-crop farming, poverty, and a large minority population. The sample comprised sixth-, seventh-, and eighth-grade stu¬ dents in 10 schools representing rural and urban settings described above (N=1601). A listing was compiled of schools representing these geographic areas that were located within 90 miles of the research hospital and that were attended by children in the age groups to be studied. Eighteen of the first 30 princi¬ pals contacted agreed to allow their schools to participate in the study. The first 10 school administrations that agreed to partic¬ ipate within the academic year for which the research was scheduled and whose schools represented the regions of concern were studied. Eighty-nine percent of the students present in all 10 schools were sampled. This sample represented 86% of the enrolled students. Members of the research team administered the questionnaire to students in each of the selected schools in spring 1990. The consent form was read aloud to each classroom, and all students were given the opportunity to have questions answered and to decline participation. After the student's written, informed con¬ sent was obtained, each student was asked to remove the con¬ sent form from his or her questionnaire to insure confidentiality. Teachers remained in the classroom, but were not involved in data collection.
Survey Tool The questionnaire was a modified version of the standardized instrument presented by Donovan et al19 that is designed to evaluate health behaviors in adolescents. This measure has been widely used to evaluate problem-behavior theory and healthrelated behavior in adolescents. Before data collection, the ques¬ tionnaire underwent numerous revisions and pilot testing in seven classrooms across geographic locations. Pretesting in dif¬ ferent locations was performed to ensure developmental appro¬ priateness and appropriateness of reading level .Thefinalsurvey contained 113 multiple-choice items and was 12 pages long. Cronbach's alpha value was .90 for the entire measure, with in¬ dividual sections ranging from .67 to .93. This measure had ad¬ equate levels of internal consistency. This index of reliability is consistent with that of other published research.12-13 However, a limitation of this measure and other measures like this is the lack of test-retest reliability indexes. Subjects were instructed to fill in the answers on their ques¬ tionnaires and computer scan sheets. Data were entered from scanned answered sheets, and incomplete answers were com¬ pared with handwritten questionnaires to maximize accuracy. The average time necessary to complete the questionnaire was
about 45 minutes. There was no evidence of respondent fatigue in finishing the questionnaire. The questionnaire solicited information about the use of fre¬ quently abused substances (alcohol, smoked and smokeless to¬ bacco, and cocaine) and associated characteristics. In addition, sociodemographic data (ie, geographic location, grade point av¬ erage, parental education, and marital status of parents) were collected to describe the adolescent and his or her family.
Data Analysis To examine the relationship between reported alcohol use and sociodemographic, personal, peer, and parental characteristics, univariate, bivariate, and multivariate analyses were employed. Standard univariate methods were performed for descriptive purposes. Bivariate analyses ( 2 and Student's t tests) were used to compare drinkers and nondrinkers and to assist in the exam¬ ination of these differences when stratified by area. MantelHaenszel statistics were computed to determine significant dif¬ ferences (P
on
Early Adolescent Alcohol
Use
Kelly J. Kelleher, MD, MPH; Vaughn I. Rickert, PsyD; Brian H. Hardin, MD; Sandra K. Pope, MPH; Frank L. Farmer, PhD studies of adolescent alcohol use have focused almost exclusively on urban and suburban youth, although alcohol is the most important drug of abuse among rural adolescents. Young adolescents, aged 11 to 14 years (N=1601), from urban, suburban, and two different rural areas (delta and highland), were surveyed about health\x=req-\ compromising behaviors, such as alcohol use. Significant differences in the number of adolescents using alcohol and the patterns of alcohol use were noted across areas by gender. Youths from the delta area, especially girls, reported drinking less frequently and in less abusive patterns than did adolescents from other areas, while youths from the highland area reported rates and patterns of drinking similar to those of urban adolescents. The reasons for intrarural variation in adolescent drinking are unknown.
\s=b\ Previous
(AJDC. 1992;146:317-322)
is an issue in the and in various pop¬ ulations to have higher rates of alcohol abuse, alcohol de¬ pendence, and problem drinking than urban populations. A recent government study concluded that, in the rural sector, alcohol is the most important drug of abuse. Na¬ tional statistics reaffirm this conclusion; predominantly rural states have higher rates of alcohol-related arrests, admissions to hospitals for treatment of alcohol abuse, and unintentional injuries associated with alcohol use compared with predominantly metropolitan states.6 Preliminary studies suggest that rural teenagers are similar to rural adults in that alcohol is the most frequent drug of abuse. High school seniors from rural areas are more likely than metropolitan seniors to report daily use of alcohol.7 Three predominantly rural states, Iowa, Montana, and North Dakota, report higher lifetime and 30-day alcohol use rates among high school seniors than the national averages.6 Among young adolescents, stud-
important health and mental health Alcohol abuse rural United States. Research conducted countries3"5 has shown rural states1-2
Accepted for publication October 8, 1991. From the Departments of Pediatrics (Drs Kelleher, Rickert, Hardin, and Pope) and Psychiatry (Dr Kelleher), University of Arkansas for Medical Sciences, Little Rock, and the Departments of Agricultural Economics and Rural Sociology (Dr Farmer), University of Arkansas, Fayetteville. Reprint requests
to
Department of Pediatrics,
Little Rock, AR 72202 (Dr Kelleher).
800 Marshall
St,
ies of a limited number of rural schools8-9 identified much higher rates of drinking and problem drinking than would be expected from national surveys. While these earlier studies are suggestive, there are very few empirically based studies that focus strictly on the prevalence of drinking among rural adolescents or the associated risk factors and patterns of alcçhol use. In general, published studies have been compromised by small sample sizes and by the use of single school sites and unstandardized measures. As a result, clear implica¬ tions for the development of treatment and prevention models for rural adolescents have not been presented.10 Nevertheless, some evidence exists to infer that preva¬ lence estimates and etiologic models of adolescent drink¬ ing from studies of urban and suburban populations may not be applicable to rural adolescents. In particular, many of the environmental factors related to alcohol use in adolescence identified in previous research may be quite different for rural teenagers. Con¬ textual variables such as parental supervision and partic¬ ular social events may be critical in determining patterns of use,1113 and these factors are likely to be different be¬ tween rural and urban communities.14 Hassinger1^ and Rogers and Burdge16 suggest that rural areas are more conservative, religious, unified, and family-centered than urban areas. How these characteristics, combined with the geographic isolation, poverty, transportation difficul¬ ties, and the unstable economy faced by many rural youth,17 impact drinking practices is unknown. However, they clearly represent a fundamentally different context for risk. Rural adolescents are an important population to study for a number of other reasons. Almost one third of all ad¬ olescents and children reside in rural areas.18 Rural ado¬ lescents are more likely to be poor and live in substandard housing than metropolitan teenagers.18 They are less likely to have health insurance and access to medical and mental health care.17 As with other youths, the vast major¬ ity of morbidity and mortality among rural adolescents is related to health-compromising behaviors,618 including alcohol use and problem drinking. The origins and risk factors related to alcohol use in rural adolescents are
poorly understood. This study was undertaken to provide insight into dif¬ ferences in the prevalence of alcohol use and patterns of drinking in rural and urban contexts as well as to assess
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/12/2015
the other variables associated with early adolescent drink¬ ing. While preliminary expectations were that urban and suburban areas would have similar prevalence rates and similar psychosocial and demographic correlates, we an¬ different rates and patterns of drinking in rural areas (greater amount consumed per occasion, but fewer occasions).9 Further, recognizing the inherent heteroge¬ neity in social and geographic conditions in rural areas, we explored the prevalence and patterns of drinking in different rural settings.
ticipated
SUBJECTS AND METHODS
Study Design
Four areas representing the diverse geography of Arkansas were studied. The urban area was a metropolitan district in which most children attended public schools. Approximately 50% of the population was black. The suburban area had a largely white population, and more children in this area at¬ tended private schools than did children in the metropolitan area. The rural area of the Ozark highlands that was selected for the study was characterized by its poultry industry and tourism and was homogeneous in racial composition (white). The fourth area, the lower Mississippi Delta region, was characterized by row-crop farming, poverty, and a large minority population. The sample comprised sixth-, seventh-, and eighth-grade stu¬ dents in 10 schools representing rural and urban settings described above (N=1601). A listing was compiled of schools representing these geographic areas that were located within 90 miles of the research hospital and that were attended by children in the age groups to be studied. Eighteen of the first 30 princi¬ pals contacted agreed to allow their schools to participate in the study. The first 10 school administrations that agreed to partic¬ ipate within the academic year for which the research was scheduled and whose schools represented the regions of concern were studied. Eighty-nine percent of the students present in all 10 schools were sampled. This sample represented 86% of the enrolled students. Members of the research team administered the questionnaire to students in each of the selected schools in spring 1990. The consent form was read aloud to each classroom, and all students were given the opportunity to have questions answered and to decline participation. After the student's written, informed con¬ sent was obtained, each student was asked to remove the con¬ sent form from his or her questionnaire to insure confidentiality. Teachers remained in the classroom, but were not involved in data collection.
Survey Tool The questionnaire was a modified version of the standardized instrument presented by Donovan et al19 that is designed to evaluate health behaviors in adolescents. This measure has been widely used to evaluate problem-behavior theory and healthrelated behavior in adolescents. Before data collection, the ques¬ tionnaire underwent numerous revisions and pilot testing in seven classrooms across geographic locations. Pretesting in dif¬ ferent locations was performed to ensure developmental appro¬ priateness and appropriateness of reading level .Thefinalsurvey contained 113 multiple-choice items and was 12 pages long. Cronbach's alpha value was .90 for the entire measure, with in¬ dividual sections ranging from .67 to .93. This measure had ad¬ equate levels of internal consistency. This index of reliability is consistent with that of other published research.12-13 However, a limitation of this measure and other measures like this is the lack of test-retest reliability indexes. Subjects were instructed to fill in the answers on their ques¬ tionnaires and computer scan sheets. Data were entered from scanned answered sheets, and incomplete answers were com¬ pared with handwritten questionnaires to maximize accuracy. The average time necessary to complete the questionnaire was
about 45 minutes. There was no evidence of respondent fatigue in finishing the questionnaire. The questionnaire solicited information about the use of fre¬ quently abused substances (alcohol, smoked and smokeless to¬ bacco, and cocaine) and associated characteristics. In addition, sociodemographic data (ie, geographic location, grade point av¬ erage, parental education, and marital status of parents) were collected to describe the adolescent and his or her family.
Data Analysis To examine the relationship between reported alcohol use and sociodemographic, personal, peer, and parental characteristics, univariate, bivariate, and multivariate analyses were employed. Standard univariate methods were performed for descriptive purposes. Bivariate analyses ( 2 and Student's t tests) were used to compare drinkers and nondrinkers and to assist in the exam¬ ination of these differences when stratified by area. MantelHaenszel statistics were computed to determine significant dif¬ ferences (P
