Alcohol Use Among Adolescents in Mongolia

1. Alcohol Use Among Adolescents in Mongolia Results from a qualitative study and experiences from a Peer Education program Miraya Jun, MSPH Fulbright Fellow Baasanbaat, MD, PsyD Mongol Urkh Kiley Larson Peace Corps Mongolia

2. Outline • What’s going on with alcohol use among adolescents in Mongolia??? • Qualitative Study Results- UB • Secondary school students, teachers, parents • Public health professionals • Mongol Urkh/Peace Corps Peer Education program • Formative results- Focus Group Discussions • Experiences

3. Mongolia’s Increasing Dependence on Alcohol 1.1. Per capita consumption of pure alcohol 9.3 7.65 4.7 1998 2000 2005 2009 Consumption Per Capita Current status of alcohol policy –Mongolia, SHORE Regional Meeting on Sustainable Alcohol policy 2010, Bangkok, Thailand

4. And its Direct consequences… Registered deaths due to alcohol intoxication Current status of alcohol policy –Mongolia, SHORE Regional Meeting on Sustainable Alcohol policy 2010, Bangkok, Thailand

5. Indirect but alarming… • Top causes of mortality • Circulatory system diseases (CVDs) • Cancers (liver, stomach) • Injuries • All 2009 rates 1.5-2.0 times higher than 2000 • All strongly associated with excess alcohol consumption WHO, 2009. STEPS

6. Injuries and Accidents • In 2008, • 63.8% of homicide violence, • 53.2% of aggravated assault • 50.0% of sexual assaults were attributable to alcohol abuse. • Traffic accidents up 2.5x in last 5 years • 2008-2009 increased 32% Ministry of Justice and Internal Affairs, 2009

7. Glasses are not the only things that are filling up… • 2614 more intoxicated persons were taken to drunken tanks for detoxification in 2008 than in 2007. • The number of underage in tanks went from 175 in 2006, to 231 in 2007, and 264 in 2008 Ministry of Justice and Internal Affairs, 2009

8. “Mostly boys use alcohol. They are placed in drunk tanks with adults- they are usually above 9th grade – 14,15 years old. It depends on the district- some police centers don’t detain those under 17. When they are able to answer questions and give contact info, they are let go with an adult escort.” -Police officer

9. Differences with past… • “Before, [adolescent drinking] never used to happen.” • “Alcohol use became excessive after democracy. …But after democracy, lots of people were out of work, … they were lost…lots of people talked about freedom but forgot about roles and responsibilities.” • ‘Mongolians considered alcohol as “devil’s spring water” “(r)arshang”. • Dual nature of alcohol use, Armstrong and Tsogtbaatar, 2010.

10. What do we know about under-age drinking?? • AAADA and World Vision 2009 • 6% -(3% females and 9% males) normally drinking 5 or more standard drinks within a drinking episode • WHO and MOH Epi Study 2006 • 2.4% females and 6.9% males reported drinking more than 20g per day • Gandulam study 2004

11. WHY? Current Qualitative study • Why do adolescents drink? • Dual nature seen in adolescents? • What can be done to address this issue? • Joint Project with Health Sciences University of Mongolia and Johns Hopkins Bloomberg School of Public Health • Mary Cwik, PhD • Saranchuluun Otgon, MA

12. FIAAMA- Factors Influencing Alcohol use Among Mongolian Adolescents • Study participants: • UB Secondary school students (12-18), • Parents, • Teachers, • Public Health Professionals ( incl. Police) • 6 schools • 4 ger district, 2 center city

13. Study Design • In Depth Interviews (IDI)- 16 participants, 27 total interviews • 6 Students • 3 Parents, 3 Teachers, 3 PH,1 Police Officer • Focus Group Discussions (FGDs), 26 participants, 4 FGDs • 4 Adults (Parents and Social Workers) • 21 Students (12-13, 15-16, 17+) • Community Task Team

14. Themes • Policy not enforced • Psychological stress • Socializing • Peer pressure • Bullying at school • Need for integrated interventions • Drinking patterns • Location of drinking • Drinking during celebrations • Age of initiation • Parent/teacher/adult- child communication • Modeling

15. Drinking Patterns • “They mostly use vodka, and when they drink, they drink until they pass out…” -13 y/o F, ger district • “80% of adolescents drink, most of our friends drink alcohol. Probably everyone had tasted alcohol.” -15-16 y/o FGD • “For children on the streets, living in the sewer pipes, drinking alcohol is their everyday habit.”-Parent, ger district • “Students from technical schools spend theirallowance moneyon alcohol.” PH professional

16. Drinking Patterns cont. • Drinking location • Pubs, cafes, lounges, internet cafes • “they don’t say anything”-13 y/o F, center city • “on the streets, in the corners somewhere…” • “outside of the school, there were a few boys probably about 6-7th grade, gathered together with paper cups, and they were using alcohol outside of the school right there.... “- Parent, g.d. • AAADA/WV- • 28.2 % In Public areas such as (bar, disco club), • 21.3% At friends homes • 35.1% Outside (street, door way, a river bank)

17. Drinking Patterns cont. • Drinking during celebrations • Graduation, school competitions, birthdays, etc. • “Most people think they can’t celebrate without alcohol.”- PH Professional • AAADA/WV- 42.1% agree celebrations are a reason to drink • Gandulam- 44.1%

18. Drinking Patterns cont. • Age of initiation • “Children who are between 8-14, when they drink, they hide under their coat. If they are above 16, they don’t hide it. Boys usually start drinking in 4th grade, girls usually start in 8th grade….” –13 y/o F, g.d. • 7th and 8th grade- 13 y/o F, c.c. • AAADA/WV-11.9 • Gandulam- 17

19. Modeling • “It has to do with how they were raised, if parents don’t drink at home, in their children’s awareness, they assume they shouldn’t drink. So if parents demonstrate drinking more, they tend to drink more.”-Parent, g.d. • AAADA/WV- 81.9% of students’ fathers and 66.1% mothers use alcohol

20. Modeling • AAADA/WV- 6.5% were sent to buy alcohol for their teachers. • “Parents influence is great on children, they should be role models. Parents bring friends home and drink so children want to imitate.” -15-16 y/o FGD • AAADA/WV- 43.2% Chose “Imitative “ as reason to drink

21. Modeling • “All adults drink, but it’s wrong, they shouldn’t because their drinking makes us feel like it’s ok.” -17-18 FGD • “Some adolescents may see that their parents’ drinking as really bad, and [the adolescents] might not drink at all because of that.” -12-13 FGD • “Most of street and homeless people pick up and collect garbage and bottles and sell them and then buy alcohol drinks… So their children basically will follow the same path. Those adults may provide alcohol drinks for these adolescents. ” –Parent g.d.

22. Parent/child communication • “Parents are busy with work, don’t have much time to talk.” 12-13 y/o FGD • “The kids who drink most are without parental supervision…”- Teacher, c.c. • ‘[Parents] hope teachers are just taking care of the children while at school, parents assume teachers are responsible, so they don’t pay attention to their kids. Parents say to teachers, “my kids would never do something like this”.’ Teacher g.d.

23. Parent/child communication • “Parents don’t really understand their kids, they don’t try …And when their children try to explain what they were doing, parents don’t accept explanation. So that doesn’t really work out because when the children get scolded, they try to hide it from their parents and they tend to use it even more.” Parent, g.d.

24. Parent/Child Communication • “It would be better if parents talked to their children about the bad effects of alcohol…If they talked in an open way, that would make a big difference instead of scolding.”- Parent, g.d. • AAADA/WV- Sources of learning about alcohol problems and danger • From parents & family members 23.8%

25. Adult FGD: • P1: “I don’t know how to talk to my daughter about alcohol.” SW: “Our parents didn’t talk to us about it.” • All student FGD participants said that they had never talked about alcohol with their parents. • “Children don’t know how to talk to parents and are afraid of getting scolded.” 15-16 y/o

26. Differences with past… • “Some parents and teachers know that kids are smoking or drinking and when those adults try to talk to the children, they don’t listen, and they argue back …” -13 y/o F, c.c. • Back in the day, if adults had something to say, the children would obey. –Parent g.d.

27. “It’s easy to get alcohol anywhere…” • “…too much availability in stores cafés and lounges should start checking IDs. They get their alcohol from stores, no one does anything. They only think about their income.”-Teacher, g.d. • AAADA/WV-55.7% of the total students in the survey said they have bought alcohol drinks.

28. Alcohol policy- media advertising • “It’s the norm. Because of media…Korean Drama TV shows, advertisement…”-PH Professional • “although restricted, alcohol is still advertized on TV. They just pay a fine because the profit is much more than the fine.” 15-16 FGD • AAADA/WV- Sources of learning about alcohol problems and danger • From TV & Radio & FM 59%

29. What do you think of this?

30. Student responses • “Young girl very innocent, naïve, she didn’t know anything about alcohol and thought it was ok to advertize alcohol”12-13 FGD • “This picture would make us want to try it” 15-16 FGD • “It’s a comparison of alcohol to a beautiful woman” 17-18FGD

31. What about this picture?

32. Student responses • “…[the beautiful girl in the advertisement] later became like the sewer lady.”-12-13 FGD • “The environment makes them not want to drink. Dirty.” 15-16 FGD • “There’s no future, it looks disgusting, It looks like if people use alcohol, they may end up like this… It looks very sad, we only get to live once, so to live like this, it’s very sad.” 17-18 FGD

33. Psychological Stress • Poverty affects psychology • wanting to escape home • …worried about their family situation… • If the parents get into fights all the time, that hurts the children’s feelings... 13 y/o F, c.c. • Some students get depressed and then drink and pass out. –PH professional • AAADA/WV- 25.7% chose easing depression as reason • 66.4% stated that they had constant stress, fear, and frustration because of family members drinking problems

34. Socializing • “When adolescents use alcohol it makes it possible for friends to stay together, to get to know each other well.” 15-16 y/o FGD

35. Peer pressure • Some children follow others and drink, and some children are forced to drink…some of them get pressured through peer pressure and beatings- 13 y/o F, c.c. • 15-16 FGD S1: “If you’re my friend, you will drink”. They might say no at first, but yes later, because they are curious. S2: To say no is the best thing and stick to it, others couldn’t force alcohol to your mouth –

36. Bullying for alcohol money • The kids who drink, when they get drunk, they go and steal, and bully other kids, especially those who are smaller… take their money…or cell phone…take the cell phones to pawn shops and that’s how they get money to buy alcohol. They tell the kids that they will beat them up more if they tell their parents. So they don’t tell their parents. -13 y/o F, g.d.

37. They do it where there are less people, so they go in big group and maybe 2 or 3 from that group would be watching for other people, and if there are other people walking by, they would pretend that they are talking to “minii duu” after people pass.. .give us money etc. if you don’t give us money, we will kill you – >15 y/o F, g.d.

38. Reasons to not drink • For health, finance, it causes adolescents to fall into using and taking risks like for girls to go to hotels. 15-16 FGD • If a child has a set of goals, they would work hard to reach the goal by practicing activities by getting involved with after school activities- they wouldn’t have time to drink.-13 y/o F, g.d.

39. What needs to happen… • S1: There are lots of drinking outside on the street, especially on Fridays, more people drink. S2: A lot of people are passed out on the street. The outside environment is very dusty, not good for children to play. Not enough playgrounds… too many bars. -12-13 FGD

40. Shops shouldn’t sell alcohol to children. • Parents shouldn’t use alcohol at home. • There should be limitations on alcohol production. -17-18 FGD

41. What needs to happen… • “...need for integrated interventions… it’s probably better to start teaching in 6th, 7th and 8th grade …11-12-13 years and they haven’t started using…”-Teacher, g.d. • AAADA/WV-33.7% learning about alcohol problems and danger from health lessons • 7.1% no info source, 79.6% want to improve knowledge

42. What needs to happen • [Police] work with schools together, and go there and participate in meetings, junior students, and give them training, for example… “ you can’t drink until you are 21.” Only Sukhbaatar district does that. -Police officer

43. What needs to happen… • … change attitudes in the long term. - PH professional • And don’t just work with adolescents but their environment. There should be more monitoring in the dormitories for those students… - PH professional

44. Speaking of interventions… • PC/MU- what is it • #Peer educators, # of trainings, # and locations of aimags reached • Video, education content • AUDIT • FGD results