Prevalence of Alcohol Consumption and Factors Influencing Alcohol Use Among the Youth in Tokorni-Hohoe, Volta Region of Ghana

: Background : Alcohol use still remains a great public health concern. However, the youth are the higher risk group in terms of alcohol consumption and its associate complications. Alcohol consumption among the youth is on the rise and Ghana cannot be exempted due to easy accessibility and availability of alcoholic beverages to the youth. According to Ghana Demographic and Health survey, alcohol consumption is highest among young people between the ages of 15-39 years than other age group; however, little information on alcohol consumption has made the problem unknown, limiting appropriate measures to control its use. This study measured the prevalence of alcohol consumption and associated factors among the youth in Tokorni-Hohoe. Methods : The study employed cross sectional study using quantitative method to sample 316 respondents. Random and systematic sampling techniques were used to sample respondents. Structured questionnaire was used to collect relevant information from respondents. The analysis was performed using StataSE 12. Results : The prevalence of alcohol consumption among the youth is 43%. Both males and females engage in alcohol use but more males were found to use alcohol than females. Alcohol consumption was highest among the age group of 20-25 years. The major factors influencing the use are peer influence (30.8%) and advertisement (20.3%). All the socio-demographic characteristics except religion ( p =0.011) and occupation ( p =0.001) were found not to be strongly associated with alcohol consumption. Reasons given by the youth for consuming alcohol are to have fun and to stimulate their appetite for food. Conclusions : Alcohol use is highly prevalent among the youth in Tokorni-Hohoe and therefore interventions to prevent its use should be more focus on the youth because of their vulnerability. Advertisement on alcohol use must be control by the appropriate institutions.


Introduction
Alcohol use among the youth forms one of the most important public health challenges despite strenuous efforts made to contain it [1]. Alcohol is considered as one of the initial substances that are used among young people before they progress to the use of more dangerous substances such as marijuana and cocaine [2]. With modernization in the world market and increase in advertisement, harmful drinks that were not easily accessible to the youth are now of higher consumption rate than expected [3]. In recent times, because of the promotion, competition and popularity of alcoholic products, most alcoholic beverages are now cheaper as compared to other soft drinks [4]. Due to this multiplicity, most young people engage in heavy drinking at younger ages than in the past.
Alcohol comes in the form of beer, wine, spirit and other alcoholic beverages. Beer include malt beer, wine from grapes, spirits from distilled beverages and other fermented beverages made from cereals such as maize, millet and sorghum [4].
Introduction to alcohol use at early age in life is another disturbing trend in youth drinking. A survey conducted in United States of America indicated that the average age of initiation to alcohol use among young people is 15 years [5]. Another survey conducted in Thai indicated that 79.7% of Thai current drinkers are over 15 years old and was reported that the youth initiate to alcohol drinking between the ages of 15-24 years [6]. In Ghana, a study conducted among second cycle and out of school youth on substance use revealed that average age for first use of substance was between 14-19 years and the highest use was between the ages of 16-23 years. In addition, substances that are mostly used by the youth in Ghana include alcohol, cigarette, cannabis and heroine [7].
Data from Ghana Demographic and Health Survey indicated that the use of alcohol is prevalent among the youth between the ages of 15-34 years in Ghana with Volta Region recording the highest prevalence among males which constitutes 42%, and among females, the highest prevalence of alcohol consumption was in Upper West Region with prevalent rate of 37% [8]. However, there is little control on the sale and consumption of alcohol among the youth in Ghana, and for this reason people in their youthful age can walk into any drinking bar to buy and consume alcohol [9]. A study conducted in a senior high school in Accra, at a mean age of 17 years found that the prevalent rate of lifetime alcohol consumption was 25.1% among lifetime users; whiles 42% were currently alcohol consumers [10].
In Africa, the rate of alcohol consumption is not different from the rest of the world because alcohol and other illicit drugs are easily accessible to the youth [11]. An empirical review of literature has demonstrated that a substantial proportion of youth in Sub-Saharan Africa have ever consumed alcohol or are currently consuming alcohol [10]. For instance, a study conducted in Uganda indicated that the country was having the highest annual consumption of pure alcohol in litres among the youth in the world [12]. Also, [13] reported in their study that one out of every three Zambian adolescents were consuming or have ever consumed alcohol.
Globally, alcohol consumption among the youth is of great concern. A worldwide survey on Alcohol and Health assessed a five year trend on alcohol consumption among the youth between the ages of 18-25 years in 82 countries and revealed that, there was 80% increase in consumption, 11% decrease in consumption, 6% stable consumption, while 12% showed inconclusive trends in consumption [14]. Again, [15] reports indicated that about 15.3 million youth between the ages of 15 to 29 years had drug disorders and 320,000 people of same age group die yearly from alcohol and drug related use, accounting for 9% of all deaths globally.
National surveys among adolescents, college students, and other young adults in the United State of America showed that youth have higher rates of alcohol intake, as well as higher rates of dangerous drinking practices such as binge drinking and daily drinking [16]. Also, a national survey conducted in Thai among the youth revealed that alcohol consumption has increased from 21.6% in 2001, to 23.5% in 2004 and to 23.7% in 2006 [6]. This indicates that globally alcohol consumption among the youth is on the rise; therefore demands urgent control measures and interventions.
The effects that usually follow alcohol use on the youth has remained a topical issue as well as a worry to parents, schools, governments and the society as a whole. Furthermore, [17] indicated that, future manpower and development of every country's economy lies on the physical and mental health of its youth. However, alcohol consumption for instance still remains major risk behaviour among the youth leading to both physical and mental health complications including deaths [1]. Most chronic and injuryrelated conditions can be attributed to excessive alcohol consumption. These include but not limited to alcohol dependence; liver cirrhosis, cancers, depression and other medical conditions [18].
Moreover, alcohol has been identified as a contributor to traumatic outcomes that either kills or disables the consumer at a relatively younger age, thereby leading to loss of many years of life to death or disability [19]. In addition, [20] further indicated in his study that the high rate of death among the youth in Nigeria is related to unhealthy lifestyles of which the use of alcohol cannot be excluded. In spite of all these problems, the use of alcohol remains unconcerned and to date is of low priority to policy makers [21]. It is therefore imperative for all countries including Ghana to adopt appropriate strategies and interventions in fighting against any physical, psychological and socio-medical problems affecting the youth due to alcohol use.
The use of alcohol varies from one location to the other [20]. In the light of this, the study was conducted in Tokorni-Hohoe to determine the prevalence of alcohol use and associated factors among the youth.

Study Site
Hohoe municipality has a total land surface area of 1,172 km 2 which constitutes about 5.6% of the Regional and 0.05% of the National land surface areas. It is situated within longitude 0° 15'E and 0° 45'E and latitude 6° 45'N and 7° 15'N and lies nearly in the middle-belt of the Volta Region of Ghana with an estimated population of 188,963 and a growth rate of 2.4. Among the Youth in Tokorni-Hohoe, Volta Region of Ghana Tokorni-Hohoe is one of the sub-communities located almost at the centre of Hohoe Township having a population of 3,914 based on the 2010 population census, with a growth rate of 2.5%. The population of the youth in Tokorni-Hohoe is about 1,488. Hohoe Township is where most travellers who are in search of job relocate making Tokorni-Hohoe one of the busiest communities in the town. The community was chosen because many and most prominent drinking bars in Hohoe Township are clustered, making alcoholic beverages easily accessible to the youth. Furthermore, the kind of entertainment provided by these drinking bars attract most people especially the youth to have fun in those places and in the process they tend to drink alcohol. This is making alcoholism becoming a serious issue among the youth in this community. The major occupation in the community is mainly petty trading. However, others engage in agricultural activities such as cultivation of Cocoa, Cassava, Rice and various vegetables notably Kontomire, Pepper and Okro. Poultry (chicken) is the leading animal reared in the municipality.
Hohoe Township has a hospital with a research centre, a private clinic, a health centre, and Reproductive and Child Health) unit with an Adolescent Health Corner. It also has four (4) tertiary institutions; a Midwifery Training School, a Public University offering courses in public health, two colleges of education, and a number of first and second cycle schools.

Study Population
Participants in the study were youths between the ages of 15-35 years. Data was collected from only those who agreed and signed informed consent form. However, individuals who have not stayed in the municipality for the past 3 months before the day of the study were also excluded from the study, as well as Non-Ghanaians and Health professionals even if they have stayed in the municipality for the required period.

Study Design
A descriptive cross sectional study using quantitative method was employed to determine the prevalence of alcohol consumption and the associated factors among the youth in the municipality between February and April, 2016.

Sample Size
Three Hundred and Sixteen (316) participants were involved, this was determined using the formula: n=z 2 xp (q)÷d 2 [22], Where n is the Sample size to be determined, z is the z-score (reliability coefficient) of 1.96 at 95% confidence level, p is the estimated proportion of an attribute that was present in the population (prevalence of alcohol consumption 0.25) [7], d is the desired level of precision 5% (0.05), and q is 1-p (0.75). For a 10% non-response rate of 288, the sample size was upwardly adjusted and rounded to 316 participants. This sample size ensured, with probability of 95% that, the estimated prevalence fell within ±5% of the true population prevalence.

Sampling Method
Multi-stage sampling method was used to select participants. A list of all the 986 houses in Tokorni-Hohoe was obtained from physical planning department in the Hohoe Municipal Assembly. Simple random sampling technique was used to select the first house and systematic sampling was then used to select every 3 rd house until all the 316 houses were selected. In houses where there were more than one household, simple random sampling was used to select one. This was done by balloting YES or NO and the household that picks YES was chosen for the study. In households where there were more eligible participants, again simple random sampling was used to select one respondent. This was also done through balloting YES OR NO, individuals who picks YES was chosen for the study.

Data Collection
A semi-structured questionnaire, pen and paper were used to obtained data from study participants on alcohol consumption and related factors through self-administration. Participants' ages were assessed using their Birth Certificates. Where certificates were not available, events calendar were used to determine their age.

Ethical Issues
The study conformed to the required ethical guidelines regarding the use of human subjects, and was approved by the Ethical Review Committee of the Ghana Health Services, Research and Development Division, Accra with protocol number GHS-ERC 08/02/16. Participation in the study was voluntary, and consent and assent was sought from the participants and their guardians.

Data Analysis
Data was entered using EPI Data version 3.1 Software and then exported to StataSE for analysis. Questions and responses were coded into numeric form for data entry. Descriptive statistics including mean, mode, percentages, and frequencies was calculated and presented in graphs and tables for quantitative variables. Beyond descriptive statistics, cross-tabulation using chi square was also used to determine the association between dependent and independent variables. The strength of the association was explored using logistic regression by computing odds ratio at 95% confidence interval, and a p-value <0.05 was considered as statistically.

Background Characteristics of Respondents
A total of 316 respondents between the ages of 15-35 were involved in the study with a response rate of 100%. Most 66.7% (211) of the respondents were males while the remaining 33.3% (105) were females. The mean age of the respondents was 23 years with standard deviation of 4.6. Almost half 46% (146) of the respondents were within the age group of 20-25, followed by 15-19 age group 28.8% (91), 26-30 age group 17.41% (55) and 31-35 age group with 7.59% (24) respectively. Majority 31.3% (99) of the respondents were either in secondary school or had completed and only 8.54% (27) of the respondents had no formal education. Only 20% (63) of the participants were married and the remaining 80% (253) were not married. More than three-fourth (76.3%) of the respondents were Christians, followed by Traditional African Worshipers (13.6%) and Moslems (10.13%) respectively. As high as 52.9% (167) of the respondents do not have any job doing. Out of the 167 participants, 35.1% (111) were students and 17.72% (56) were unemployed. Respondents who were employed constituted 47.1% (149) ( Table 1).

Youths Currently Consuming Alcohol
As high as 43.4% of the youths in Tokorni-Hohoe community are currently consuming alcoholic beverages, however, almost 70% of the youth had once in their lifetime ever consumed alcohol (Figure 1).

Alcohol Consumption and Background Characteristics
More 101 (73.7%) males consume alcohol than females 36 (26.2%). However, sex specific analysis indicated that out of the 211 male participants, 47.9% are currently consuming alcohol while 34.3% out of the 105 female participants are also consuming alcohol currently. Approximately, 45% of the respondents who are currently consuming alcohol are among the age group of 20-25 years and the least (11%) among the age group of 30-35 years. Out of the 43% (137) of the respondents who are currently consuming alcohol, 86% (118) had some level of education while 13% (19) had no education. Again, out of the 137 participants who are currently consuming alcohol, 72.9% (100) were not married whiles 27% (37) were married. More than half 54.74% (75) of current alcohol consumers were employed whiles 45.26% (62) was among artisans (Table 2).

Frequency of Alcohol Consumption Among Youth
The study also show that 16% of the youth in the community consume alcohol on daily basis, while 22.1%, 17.41% and 13.6% consumed alcohol weekly, monthly and yearly respectively (Figure 2).

Types of Alcohol Consume by the Youth
The study indicated that alcoholic beverage mostly consumed by the youth in Tokorni-Hohoe was beer (34%), followed by wine (31%), 'spirit' constituted 21% while 14% of the respondents also do not have choice but consume all the alcoholic beverages ( Figure 3).

Factor Contributing to Alcohol Consumption Among the Youth
Almost one-third (30.8%) of the youth are into alcohol consumption due to peer influence, 20.3% also attributed alcohol consumption to advertisement, 12.7% were based on easy availability and accessibility, 12.2% on social networking, 9.3% also attributed alcohol consumption to parental influence whiles 14.7% attributed it to curiosity ( Figure 4).

Associations Between Alcohol Consumption and the Background Characteristics
There is significant associations between alcohol consumption and sex (p=0.02), age (p=0.01), level of education (p=0.03), religion (p=0.02), and occupation (p<0.001). To further explore the strength of associations, multiple logistic regression analysis was done to confirm the association between alcohol consumption and independent variables. The analysis confirmed strong association between alcohol consumption and religion (p=0.011), and occupation (p=0.001). However, it did not confirm an association between alcohol consumption and age, sex, and level of education. The associations also indicated that females were 43.0% less likely to consume alcoholic beverage than males. Furthermore, individual within the ages of 20-25 years and 26-30 years were 2 times whiles those within 31-35 years age group were 4 times more likely to consume alcohol than individual within the ages of 15-19. Youth with primary, JHS/Middle, Secondary and Tertiary education were 62.0%, 67.0%, 81.0% and 62.0% respectively less likely to consume alcohol than individual with no education. Also, traders (26.0%), artisans (36.0%) and students (75.0%) were less likely to consume alcoholic drinks than unemployed individuals. Traditional worshippers were 9.1 times more likely whiles Muslims were 87.0% less likely to consume alcohol than Christians (Table 3).

Discussion
Data was collected from 316 respondents aged 15-35 years. Males (66.7%) who participated in this study were almost twice the number of females (33.3%). This was due to the fact that most females were unwilling to disclose their alcohol use possibly because society frowns on females who consume alcohol. This gender distribution is not surprising because it is consistent with previous studies conducted by [1 & 23], whose study also reveals more males participation than females. Most of the respondents who consume alcohol were in their active age (20)(21)(22)(23)(24)(25) which accounts for approximately 45% and the least was recorded among the age group of 31-35. This indicates that alcohol consumption decreases with increasing age, and this finding is also supported by the result of Ghana Demographic and Health Survey [8].
The findings indicate that the prevalence of alcohol consumption among the youth in Tokorni-Hohoe was 43%. This prevalence is higher than a national survey conducted in Ghana with results indicated 25% prevalence of alcohol consumption among the youth in Ghana [7]. The significant difference can be attributed to unrestricted access or increase number of drinking bars in the community making alcoholic beverage easily accessibility to the youth therefore increasing alcohol consumption.
Majority of males (73.7%) are currently consuming alcohol while the number of females' currently consuming alcohol is 26.3%. This findings is in line with a study conducted to know the prevalence of psychoactive substance use among the youth, where their findings also indicated that males (67%) were consuming alcohol whiles (33%) females were consuming alcohol [23]. The reason may be due to gender difference because society encourage males' alcohol consumption but not female alcohol consumption.
Findings on how frequent respondents consume alcohol indicate that more males consumed alcohol on a typical day than their female counterparts. Again, more males were found to consume alcohol within the preceding week than females. This finding is in line with a study conducted by [8 & 24] who found that males consume more alcohol on a typical day or weekly than females. This could be that, males are more likely to be stressed up after a hard physical day's work, so they result in drinking alcohol to release their stress.
The result indicated that most of the youth consume more alcohol weekly, followed by monthly, daily and yearly respectively. This finding is similar to a study conducted in Nigeria to know some factors on alcohol use and abuse among University students, and their findings show that alcohol was mostly consumed daily and weekly [20].
Alcoholic beverages that were mostly consumed by the youth were in the form of beer, wine and spirit respectively. This is an indication that most of the youth are at risk of developing lung cancer because a review of epidemiology evidence on alcohol and lung cancer shows that individuals who consume beer are at higher risk of developing lung cancer [25]. This finding also agrees with [12] survey in Gambia among the youth, which found out that beer was mostly used by the youth, followed by wine and spirit. This could be that, beer is one of the alcoholic beverages that are mostly advertised on social media and the youth out of curiosity want to know how it tastes, therefore increasing it consumption.
There was significant association between alcohol consumption and all the socio-demographic factors except marital status. Surprisingly, the likelihood of alcohol consumption among females was higher as compared to males. This is probably due to women empowerment where females are now empowered to compete with their male counterpart. However, this finding is not consistent with a study conducted by [26] who found that males are more likely to consume alcoholic beverage than females.
There was an association between alcohol consumption and age. Alcohol consumption was found to be highest among the age group of 20-25 and lowest within the age group of 31-35. This result indicated that alcohol consumption decreases with increasing age. This means that young individuals are more likely to consume alcohol than adults. On the contrary, the finding disagrees with [23 & 27] who found that alcohol consumption increases with increasing age. The difference may be due to the fact that their study was conducted in their various countries therefore having a larger sample size, whiles this study was only focused on one community.
Alcohol consumption was significantly associated with educational level. The highest alcohol consumption was found among JHS/Middle and the least was recorded among primary students and individuals with no formal education. This indicates that the individuals with higher education are more likely to consume alcohol than those without formal education. This finding is supported by a previous study conducted by [8].
With regard to marital status, unmarried individuals were more likely to consume alcohol than married women. Similarly, these findings is consistent with national survey on substance use among the youth in Ghana [7].
There was a strong association between alcohol consumption and religion. Muslims were less likely to consume alcohol than Christians or a traditionalist. This is because the doctrine of Muslims prohibits the use of alcohol in any of their activities whiles Christians and Traditional Worshippers use alcohol in most of their activities such as weddings, funerals and pouring libation. This is not supported by a study conducted by [28] and the disparities may be due to differences in environment.
The results indicate that employed individuals were more likely to consume alcohol than unemployed individuals. This may be due to the fact that employed individual can afford most of the alcoholic beverage so they drink it whenever they feel like drinking alcohol. However, when further multiple regression analysis was done, there was strong association between alcohol consumption and religion, and occupation but it did not confirm the association between alcohol consumption and age, sex, marital status and educational level. This was due to confounding factors that were not accounted for in the study. Out of the listed factors that influence the youth to consume alcohol, almost three-fourth of the respondents attributed alcohol consumption to peer influence, followed by advertisement and easy availability or accessibility. Others attributed alcohol consumption to social networking, parental influence and curiosity respectively. These findings conform to a study conducted by [29] also found that peer influence is the major factor that influences alcohol consumption. This result indicates that the youth are more prone to peer pressure, and for them to be accepted among their peers, they also have to consume alcohol to please them. This increases the likelihood of alcohol consumption among the youth whose peers are drunkards.
Responses from the respondents indicate that most of the youth consume alcohol to have fun, followed by using it as an appetizer, to relax, to cope with stress, to satisfy partner, imitating role model and unemployment was the least factor. This findings were consistent with a study conducted [1] who also found similar reasons associated with substance use in secondary school student.
Frequency distribution of how people feel when they are able to consume alcohol shows that majority of the respondents feel matured when they drink alcohol, followed by feeling happy and feeling richer than peers. Others feel brave, failure, and prosperous when they drink alcohol. This feeling only lasts for a short period of time considering its chronic health effects on the youth.

Conclusion
Generally, both males and females were found to consume alcohol; however females were less likely to consume alcohol than males. Beer was the commonest alcoholic beverage consume by the youth. Most of the respondents revealed that peer influence is the major factor that influences alcohol consumption. Alcohol use was mostly attributed to having fun but these feelings are ephemeral, considering its chronic effect on the youth.

Recommendations
Central Government and policy makers at the local level should enact policies to restrict the sales of alcohol to the youth and also limit ages that have access to alcohol. The DHMT should incorporate campaigns against alcohol both in-school and out-of-school programmes, to mitigate the use of alcohol among the youth if not total abstinence. Health promoters should include negative effects of alcohol consumption in their health messages to sensitize the youth on the harmful effects of alcohol. Parents should also monitor their children's behaviour to reduce the likelihood of their peers introducing them to alcohol consumption. Researchers should conduct similar studies in the Hohoe Municipality in order to know the true prevalence of alcohol among the youth in the Municipality. Further, researchers should also conduct studies to determine the prevalence of lung cancer among the youth in the community.