Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends

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Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends Jianhui He a,1 , Sawitri Assanangkornchai b,∗ , Le Cai c,1 , Edward McNeil b,2 a Department of Health Economics and Health Management, School of Public Health, Kunming Medical University, Chun Rong West Road 1168, Yu Hua Street, Chenggong New City, Kunming, Yunnan Province, PR China b Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla 90110, Thailand c School of Public Health, Kunming Medical University, Chun Rong West Road 1168, Yu Hua Street, Chenggong New City, Kunming, Yunnan Province, PR China

a r t i c l e

i n f o

Article history: Received 16 April 2015 Received in revised form 27 November 2015 Accepted 18 December 2015 Available online xxx Keywords: Risky drinking Ethnic groups Acculturation Religion Social drinking environment

a b s t r a c t Objective: Studies investigating alcohol consumption related factors have rarely focused on the relationship between acculturation, religion and drinking patterns. The objective of this study is to explore the predictors of drinking patterns and their mutual relationships, especially acculturation, ethnicity and religion. Methods: A cross-sectional household survey using a multistage systematic sampling technique was conducted in Yunnan Province of China. A revised Vancouver Index of Acculturation (VIA) and Alcohol Use Disorder Identification Test (AUDIT) Chinese version were used to measure acculturation and drinking patterns. Structural equation modeling (SEM) was used to explore the structures of how predictors affect drinking patterns. Results: A total of 977 subjects aged 12–35 years were surveyed. A higher percentage of binge drinking was found among Lisu people. However, the proportion of drinking until intoxication was highest among Han. Gender and enculturation had both direct (standardized ˇ = −0.193, −0.079) and indirect effects (standardized ˇ = −0.126, 0.033) on risky drinking pattern; perceived risk of alcohol consumption (−0.065), family drinking environment (0.061), and friend drinking environment (0.352) affected risky drinking pattern directly, while education level (0.066), ethnicity (−0.038), acculturation (0.012), religious belief (−0.038), and age group (0.088) had indirect effects. Conclusion: Risky drinking pattern was associated with gender and aboriginal culture enculturation both directly and indirectly, and related to mainstream culture acculturation and religious belief indirectly. Other demographic (such as education level) and social family factors (friend drinking environment for example) also had effects on risky drinking pattern. © 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Harmful use of alcohol is a public nuisance around the world. From 2006 to 2010, alcohol consumption in China has increased, which could be related to the fact that China has now become the largest beer-producing country in the world (Tang et al., 2013) as

∗ Corresponding author. Fax: +66 74 429754. E-mail addresses: [email protected] (J. He), [email protected] (S. Assanangkornchai), [email protected] (L. Cai), [email protected] (E. McNeil). 1 Fax: +86 71 65922911. 2 Fax: +66 74 429754.

well as aggressive marketing tactics used by the alcohol industry and an increasing income of Chinese residents. It is important to document influencing factors for alcohol consumption to guide preventive measures. There have been several studies investigating influencing factors of alcohol consumption around the world (Bécares et al., 2011; Casswell et al., 2003; Garmiene˙ et al., 2006; McKay, 2015; Newman et al., 2004), but few have focused on the relationship between acculturation, religion and drinking patterns in China. Aboriginal culture enculturation has been found to be an important protective factor for alcohol consumption (Cheah and Nelson, 2004; Currie et al., 2013, 2011). Enculturation refers to the process of retaining ingredients of one’s aboriginal culture (Weinreich, 2009). The quest of aboriginal culture as a possible protective factor

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Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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in alcohol consumption is a new exploration in China. Acculturation refers to the process that occurs when groups of individuals of different cultures come into continuous first-hand contact, which changes the original cultural patterns of either or both groups (Rothe et al., 2010). With the changes and economic development of the society, alcohol drinking among ethnic minority people in China is not limited only in sacrifice activities and celebrations but also affected by modernization and the Han majority culture (Jianhua et al., 2010). There are two major theories underlying acculturation research: one-dimensional and bi-dimensional models. The one-dimensional model does not allow ethnic minorities to hold full bicultural identities, although many ethnic minorities describe themselves as such, while the bi-dimensional model is able to embrace not only individuals with bicultural identities but also people who are not attached to either culture (Kang, 2006). Ryder and colleagues developed a bi-dimensional acculturation scale, called the Vancouver Index of Acculturation (VIA; Ryder et al., 2000). A modified version of this scale was used in our study to explore the level at which aboriginal people recognized the mainstream and aboriginal cultures separately and the level to which they were in accordance with aboriginal and mainstream customs without determining what those customs would be (Currie et al., 2011). Huynh’s meta-analysis and Currie and colleagues’ studies showed that the reliability of VIA was robust (Currie et al., 2013; Huynh et al., 2009). The bi-dimensional acculturation measured by VIA and its association with alcohol use and other behaviors was supported by some studies. High heritage acculturation group compared to low heritage acculturation and the majority groups were found to have less alcohol consumption and their alcohol use behaviors are more similar to the original culture background (Cheah and Nelson, 2004; Currie et al., 2013, 2011). Although acculturation was used to measure people’s behaviors among the immigrants, the idea of assimilation or dissimilation of culture affects each other is the same. In our study, we modified the VIA to be suitable for the cultures of Chinese ethnic groups. Alcohol consumption among different ethnic groups varies from country to country and from generation to generation. In general, people from low alcohol consumption background countries drink less compared to those who come from higher alcohol consumption background countries (Bécares et al., 2011; Bayley and Hurcombe, 2011; Lum et al., 2009; Van Tubergen and Poortman, 2010). Second generation immigrants are more likely to have behaviors which are more similar with native people, compared to the first generation (Amundsen, 2012). Religious belief is a behavior regulation tool, which can strongly affect a person’s behavior. Studies have shown that, compared to people who have no religious belief, having a religious belief is a protective factor for alcohol drinking (Lucchetti et al., 2014; Sinha et al., 2007; Tumwesigye et al., 2013). Family and friend related factors have also been found to be associated with risky drinking. Studies have shown that in a family containing many drinkers or risky drinkers, family members are more prone to drink and to have a risky drinking pattern (Beal et al., 2001; Yu, 2003). People who have more drinking friends tend to drink alcohol and have risky drinking patterns (Donovan, 2004; McKay, 2015; Newman et al., 2004; Ryan et al., 2010; SimonsMorton, 2004). Except for the above mentioned factors, female gender (Holmila and Raitasalo, 2005; Ma et al., 2006; Wilsnack et al., 2009), age (Kim et al., 2013; Wilsnack et al., 2006; Wolff et al., 2014), marital status (Bogart et al., 2005; Kearns-Bodkin and Leonard, 2005; O’Malley, 2004), education (Caldwell et al., 2008; Casswell et al., 2003; Cutler and Lleras-Muney, 2006; Huerta and Borgonovi, 2010) and people’s perceptions of the risk of alcohol consumption on the body (Bühler

et al., 2015; Grevenstein et al., 2015; Henry et al., 2005) are related to the level of risky drinking. Our study hypothesis is that aboriginal culture enculturation is associated with a reduced risk of drinking and mainstream culture acculturation is associated with an increased risk of drinking. Having religious belief and increased perceived risk of alcohol consumption are related to a reduced risk of drinking, while family and friend drinking environment increases the risk of drinking. In the present study, we explored the relationship between risky drinking and associated factors via a structural equation model using the VIA, Alcohol Use Disorder Identification Test (AUDIT; Babor et al., 2001) and structured interview-based questionnaire. The results of this study should provide knowledge about cultural and other related factors of alcohol consumption among ethnic people in China. 2. Materials and methods 2.1. Participants, recruitment settings and sampling procedure 2.1.1. Participants, recruitment settings. We conducted a cross-sectional study with a multistage systematic sampling method in Lushui and Luquan counties of Yunnan Province of China during February and April, 2014. The criteria for inclusion were individuals who were Han, Lisu or Yi ethnicity, aged 12–35 years old and living in these counties for at least six months. The Ethics Review Committee of the Faculty of Medicine, Prince of Songkla University, approved the study protocol. Written informed consent was obtained from all participants before the interview. 2.1.2. Sampling procedure. Two counties were selected purposively because they had high populations of the study ethnicities, were easy to access and had good cooperation by the local government staff. Three out of nine townships in Lushui County having high proportions of Lisu people and six out of twelve townships in Luquan County having high proportions of Han and Yi ethnicities were purposively selected. By this selection method, three sets of three townships each with high proportions of Lisu, Yi and Han ethnicities were obtained. Among each township, three villages were selected using systematic sampling based on the list of villages in the selected township. Because of the mountainous geographical terrain and having no authoritative map or household archives, successive households, starting from the one closest to the village health unit within the chosen village, were sampled until the required sample size was achieved. Within the chosen family, all eligible respondents were invited to join the survey. If a respondent was absent from home, the house was revisited. If the respondent was absent from home on the second visit, a neighboring house was visited. 2.2. Measures 2.2.1. Social and demographic variables. Data on demographic characteristics, social and alcohol consumption related factors were derived from a structured interviewbased questionnaire. Demographic variables included age (stratified later to 12–18, 19–24 and 25–35 years, based on the average ages of attending junior and senior high school, college, and work in China), gender, education level (primary school and below, junior high school, senior high school and above), ethnicity (Han, Lisu and Yi), marital status (single, married, divorced/separated/widowed), income and occupation (student, farmer and others). Religious belief was measured by asking the question “what is your religious background?” and respondents could choose Buddhism, Christianity, Islam, Catholicism, no religious belief or other. Family drinking environment was measured by asking about the number of drinkers in the family, parental attitude on children’s drinking and accessibility of alcohol in the home. Social drinking environment included exposure to alcohol advertisements and number of friends who drank and the number who became intoxicated. Attitude toward alcohol provided by a best friend was collected by asking the question “If one of your best friends offered you an alcoholic drink, would you drink it?” with the options being “Definitely not”, “Probably not”, “Probably yes”, and “Definitely yes”. Perceived risk of alcohol consumption included three questions asking “How much do you think people risk harming themselves (physically or in other ways), if they drink alcohol once or twice a year?, if they drink alcohol several time a week?, and if they get drunk once a week?” with possible responses being “No risk”, “Slight risk”, “Moderate risk” and “Great risk”. 2.2.2. Acculturation measure. Acculturation was measured using a modified Vancouver Index of Acculturation (VIA; Ryder et al., 2000). The scale includes two subscales which estimate aboriginal culture enculturation (heritage subscale) and mainstream culture acculturation. The answer of each item was modified from a nine-point scale (strongly disagree, disagree, moderately disagree, mildly disagree, neutral, mildly agree, moderately agree, agree, and strongly agree) to a five-point scale (strongly disagree, disagree, neutral, agree, and strongly agree). We believed that this modification would make it easier for local people to answer the questions.

Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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Table 1 Demographic characteristics of respondents. Characteristic

Han

Lisu

(n)

(%)

Gender Male Female

178 148

54.6 45.4

Age group 12–18 years 19–24 years 25–35 years

89 60 177

Religious belief No Yes

Yi

Total

(%)

(n)

(%)

(n)

(%)

150 164

47.8 52.2

179 158

53.1 46.9

507 470

51.9 48.1

27.3 18.4 54.3

79 59 171

25.6 19.1 55.3

111 42 184

32.9 12.5 54.6

279 161 532

28.7 16.6 54.7

273 53

83.7 16.3

238 76

75.8 24.2

241 96

71.5 28.5

752 225

77 23

Educational level Primary school and below Junior high school Senior high school and above

110 159 57

33.7 48.8 17.5

168 119 26

53.7 38 8.3

157 147 33

46.6 43.6 9.8

436 425 116

44.6 43.5 11.9

Marital status Married Not marrieda

177 149

54.3 45.7

186 128

59.2 40.8

183 154

54.3 45.7

546 431

55.9 44.1

Occupation Farmer Student Other

205 73 48

62.9 22.4 14.7

230 62 22

73.7 19.7 7.1

219 97 21

65.0 28.8 6.2

654 232 91

67.1 23.6 9.3

Income levelb (RMB: Yuan) <=10000 10000–30000 >30000

53 131 142

16.3 40.2 43.6

104 126 84

33.1 40.1 26.8

49 140 148

14.5 41.5 43.9

206 397 374

21.1 40.6 38.3

a b

(n)

Including: single, separated, widowed and divorced; income level was categorized by P25 and P75 of the total population. RMB: Chinese currency.

2.2.3. Alcohol risky drinking pattern measure. Measures of risky drinking pattern included binge drinking, drinking until intoxication and the AUDIT. Binge drinking was defined as drinking at least 60 g of pure ethanol on a drinking occasion for both males and females. Respondents were classified according to AUDIT scores as either abstainers/low risk drinkers (respondents whose AUDIT score was between 0–7), or moderate and high risk drinkers (respondents whose AUDIT score was equal to or greater than 8). In our study regions, the concept of a standard drink is not applicable to the local residents. Because of this, we asked the quantity of drinking in terms of containers familiar to them, such as glass, cup, or bottle, and measured the size of the container. We then calculated the average volume of alcohol intake in a drinking occasion using the beverage specific quantity frequency (BSQF) questionnaire. Average daily intake and drinking intensity were calculated by dividing the annual volume by 365 and the number of drinking days per year, respectively. The BSQF method used two questions to measure consumption of each type of beverage in the last year, (a) ‘in the last 12 months how often did you have an alcoholic drink?’ (options: every day, 5–6 days per week, 3–4 days per week, 1–2 days per week, 2–3 days a month, one day a month, 7–11 days a year, 4–6 days a year, 2–3 days a year, once in the past year and no drink in the past year); and (b) ‘on a day that you drink alcohol, how much do you usually drink (beer, wine, spirits and home-made alcohol)?’

factory (Tavakol and Dennick, 2011). A p-value less than 0.05 was used to indicate statistical significance.

3. Results 3.1. Demographic characteristics Among 977 eligible subjects identified during the home visits, 326, 314 and 337 were Han, Yi and Lisu ethnicity, respectively. The distribution of gender, age and marital status among the three ethnic groups were similar. About 55% of each ethnic group were aged 25–35 years. Han people achieved a higher education, had a higher annual family income and were engaged in other types of work such as teaching more than Yi and Lisu. The proportion having a religious belief was lower among Han compared to the other two groups (Table 1). 3.2. Acculturation by ethnic groups

2.3. Data management and statistical analysis Data were entered and validated using Epidata (The EpiData Association, Odense, Denmark), version 3.1. R software version 3.0.3 was used for data analysis. Chi-square tests and rank sum tests were used for comparison of risk levels in univariate analysis. Structural equation model (SEM) analysis with Bayesian estimation (Lee and Song, 2003) was used to explore the relationship between variables. SEM permitted us to clearly fit both direct and indirect effects. When the p-value from univariate analysis was less than or equal to 0.1, the variable was kept for further structural equation model analysis. Selection of variables to construct the equation structure and model fitting strategy were based on literatures and univariate analysis. A stepwise exploration based on goodness of Chi-square statistic, root mean square error of approximation (RMSEA), adjusted goodness of fit index (AGFI), and comparative fit index (CFI) were used to choose the best fitting model. A statistically non-significant model Chi-square statistic, RMSEA lower than 0.05, AGFI greater than 0.90, and CFI greater than 0.95 indicated a good fit (Byrne, 2013; Hu and Bentler, 1999). The direct and indirect effects were applied to describe the effects of the predictors on the dependent variable. Cronbach’s alpha was used to test the reliability of scales, a value between 0.70 to 0.95 being regarded as satis-

Cronbach’s alpha for the VIA scale was 0.90 (heritage subscale ˛ = 0.92, mainstream subscale ˛ = 0.89), and the Cronbach’s alpha of the AUDIT scale was 0.85. Regarding marriage with someone of one’s own ethnic or other ethnic group, Lisu people were more conservative compared to Han and Yi people. Han people tended to enjoy their own culture for entertainment. Regarding acculturation items, the mean scores of the following items were lower among Lisu people compared to Han and Yi people: participating in mainstream traditional activity, having social activity with mainstream people, feeling comfortable when interacting with mainstream people, behaving in a way that is consistent with mainstream people, having a view on keeping the mainstream culture, and having mainstream people as friends. Yi (35.2) had the highest mean score of acculturation compared with Han (34.5) and Lisu people (33.6) (Table 2).

Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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Table 2 Acculturation scale item mean score distribution by ethnicity. Items

Han (n = 326)

Lisu (n = 314)

Yi (n = 337)

Mean

sd

Mean

sd

Mean

sd

4.4 4.2 4.3 4.3 4.3*** 3.9 4.2 4.0 4.2 4.3

0.7 0.8 0.7 0.7 0.8 0.9 0.8 0.9 0.7 0.7

4.4 4.3** 4.3 4.3 4.1 4.0 4.2 4.1* 4.2 4.3

0.6 0.7 0.6 0.6 0.8 0.9 0.8 0.7 0.7 0.6

4.3 4.1 4.2 4.2 4.0 3.9 4.2 4.0 4.1 4.2

0.8 0.9 0.8 0.8 1.0 0.9 0.9 0.9 0.8 0.8

42.2 Enculturation score 2. I often participate in mainstream Chinese cultural traditions (in other ethnic cultural traditions-for Han) 3.5 4. I would be willing to marry a Chinese Majority (Han) person (to marry other ethnic cultural person-for Han) 3.4 6. I enjoy social activities with typical Chinese Majority (Han) people (with other ethnic culture people) 3.6 3.7 8. I am comfortable interacting with typical Chinese Majority (Han) people (with other ethnic culture peoplefor Han) 10. I enjoy Chinese Majority (Han) entertainment (e.g. movies, music)(other ethnic culture entertainment-for Han) 3.3*** 12. I often behave in ways that are typically Chinese Majority (Han)(other ethnic culture-for Han) 3.1 3.9 14. It is important for me to maintain or develop Chinese Majority (Han) cultural practices (other ethnic cultural practices-for Han) 3.2 16. I believe in mainstream Chinese Majority (Han) values (other ethnic culture values-for Han) 3.3*** 18. I enjoy Chinese Majority (Han) jokes and humor (other ethnic culture jokes and humor-for Han) 3.7 20. I am interested in having Chinese Majority (Han) friends (other ethnic friends-for Han)

5.9 0.9 1.0 0.8 0.8

42.3 3.3*** 3.2* 3.4* 3.4***

4.9 1.0 1.1 1.0 0.9

41.2 3.5 3.3 3.5 3.7

7.1 1.0 1.1 1.0 0.9

1.0 0.9 0.9

3.7 3.0** 3.6***

1.1 0.9 0.9

3.7 3.1 3.9

1.0 1.0 1.0

0.9 1.0 0.9

3.1 3.5 3.4***

0.9 0.9 0.9

3.2 3.5 3.7

1.0 1.0 1.0

Acculturation score

6.4

7.0

35.2***

7.0

1. 3. 5. 7. 9. 11. 13. 15. 17. 19.

* ** ***

I often participate in my ethnic cultural traditions I would be willing to marry a person from my ethnic culture I enjoy social activities with people from the same ethnic culture as myself I am comfortable interacting with people of the same ethnic culture as myself I enjoy entertainment (e.g. movies, music) from my ethnic culture I often behave in ways that are typical of my ethnic culture It is important for me to maintain or develop the practices of my ethnic culture I believe in the values of my ethnic culture I enjoy the jokes and humor of my ethnic culture I am interested in having friends from my ethnic culture

34.5

33.6

p < 0.05. p < 0.01. p < 0.001, when compared with other two groups.

3.3. Drinking patterns and risk levels by ethnicity Table 3 shows drinking indices and AUDIT risk levels by ethnicity. Lisu people had a significantly higher daily intake and drinking intensity than did Han and Yi (p < 0.05). They also drank more industry-made spirits and beer. A significantly higher percentage of binge drinking was found among Lisu people, compared to Han and Yi (p < 0.05). However, the proportion of drinking until intoxication was highest among Han (p < 0.01). The percentages of moderate and high risk AUDIT levels were similar between Han and Lisu but much lower among Yi. 3.4. Determinants of moderate and high risk drinking by univariate analysis Table 4 shows that the proportions of moderate and high risk drinking were lower among females, Yi, and students (p < 0.001), compared to males, other ethnic groups and other occupation groups, respectively. Younger people (19–24 years), those who attained higher education, knew the reason why others drink, current smokers (p < 0.001) and those with higher acculturation were more likely to be classified as moderate-high risk drinkers (p < 0.01). A dose-response relationship was found in the associations between risky drinking with frequency of seeing alcohol advertisements on TV, family drinking environment, friend drinking environment (p < 0.001) and perceived effect of alcohol consumption on the body (p < 0.01). 3.5. Predictors of risky drinking pattern by structural equation model analysis 3.5.1. Fitness of measurement. The overall indices of fit for the final structural model were as follows: Chi-square = 33.07 (df = 37, p = 0.64), RMSEA = 0.000 (90% CI: 0.000, 0.019), AGFI = 0.995, CFI = 1.000. All indices indicated that the final model fitted the data well. Fig. 1 shows the structural model of the association

between risky drinking with demographic characteristics (gender, age group, ethnicity, education level and marriage), religious belief, current smoking status, perceived risk of alcohol drinking, family drinking environment, friend drinking environment, enculturation (heritage culture) and acculturation (mainstream culture). There were five predictors directly affecting risky drinking pattern of alcohol while eight were found to have an indirect effect. The predictors shown in Fig. 1 could explain 24% of the variance of risky drinking pattern of alcohol, 35% of the variance of current smoking, and 25% of the variance of friend drinking environment. 3.5.2. Direct and indirect effects. As shown in Table 5, enculturation (ˇ = −0.079, 95% CI: −0.134, −0.024) was a direct protective factor for risky drinking while acculturation (ˇ = 0.012, 95% CI: 0.012, 0.036) was an indirect risk factor. Religious belief (ˇ = −0.038, 95% CI: −0.060, −0.016) and ethnicity (ˇ = −0.038, 95% CI: −0.060, −0.016) were indirectly related to reduced level of risky drinking. Female gender was a protective factor both directly (ˇ = −0.193, 95% CI: −0.252, −0.134) and indirectly (ˇ = −0.126, 95% CI: −0.157, −0.103) on risky drinking. Other demographic factors, such as education level (ˇ = 0.066, 95% CI: 0.043, 0.091), and age group (ˇ = 0.088, 95% CI: 0.064, 0.112) were indirectly related to the level of risky drinking. Perceived risk of alcohol consumption (ˇ = −0.065 95% CI: −0.120, −0.010) was directly associated with reduced level of risky drinking while family (ˇ = 0.061, 95% CI: 0.002, 0.120) and friend (ˇ = 0.352, 95% CI: 0.291, 0.413) drinking environment were related to increased level of risky drinking. 4. Discussion The SEM method used in the present study generated a good statistical fit to our sample data. The direct negative effect of enculturation on risky drinking, which is consistent with previous studies (Cheah and Nelson, 2004; Currie et al., 2013, 2011), may come from the effect of one’s native culture. Currie and colleagues noted that indigenous cultural practices may prevent

Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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Indices

Han (N = 326) a

Low risk Moderate risk High risk

Yi (N = 337)

Total (N = 997)

(n)

Median (IQR) or (%)

(n)

Median (IQR) or (%)

(n)

Median (IQR) or (%)

(n)

Median (IQR) or (%)

110

2.1 (0.5, 10.4)

109

5.3 (0.9, 17.0)**

102

2.1 (0.2, 6.3)

321

2.6 (0.4, 10.4)

110

35.5 (17.5, 66.4)

109

40.2 (24.2, 72.7)

102

33.2 (16.9, 50.8)

321

33.8 (17.8, 65.2)

110

954.7 (136.1, 3231.1)

109

1406.2 (213.0, 5391.3)

102

591 (114.8, 3521.0)

321

940.7 (152.5, 3839.0)

60

1106.0 (508.4, 3347.6)

11

1990.8 (964.4, 11502.4)

21

1137.6 (474.0, 3981.6)

92

1232.0 (508.4, 4782.0)

9

11322.7 (616.2, 15610.4)

27

1023.8 (305.7, 2538.3)

19

900.6 (388.7, 5196.6)

55

1024.0 (369.7, 5542.0)

105

507.7 (100.7, 1523.0)

89

1028.6 (198.0, 3716.5)*

72

395.6 (100.4, 1586.4)

266

550.3 (137.8, 2150.0)

59 94

18.1 28.8**

65 70

20.7* 22.3

42 63

12.5 18.7

166 227

17 23.2

269 43 14

82.5 13.2 4.3

259 40 15

82.5 12.7 4.8

299 29 9

88.7 8.6 2.7

827 112 38

84.6 11.5 3.9

AUDIT: Alcohol Use Disorder Test. * p < 0.05. ** p < 0.01, when compared with the other two groups. a number of drinkers.

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Average daily intake for all beverages (g/day) Drinking intensity for all beverages (g/drinking day) Annual per drinker consumption for all beverages (g/year) Annual per drinker consumption for industry made spirits (g/year) Annual per drinker consumption for home made spirits (g/year) Annual per drinker consumption for beer (g/year) Binge drinking (%) Drinking until intoxication (%) AUDIT risk level (%)

Lisu (N = 314)

J. He et al. / Drug and Alcohol Dependence xxx (2015) xxx–xxx

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Table 3 Patterns of alcohol consumption and AUDIT risk level by ethnicity.

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Table 4 Univariate analysis of determinants for alcohol consumption differed by risk level of AUDIT. Indices

Low risk n (%)

Moderate and higher n (%)

Gender Male Female

371 (73.2) 456 (97.0)

136 (26.8) 14 (3.0)

Age group 12–18 years 19–24 years 25–35 years

262 (93.6) 125 (77.2) 440 (82.2)

18 (6.4) 37 (22.8) 95 (17.8)

Ethnicity Han Lisu Yi

269 (32.5) 259 (31.3) 299 (36.2)

57 (38.0) 55 (36.7) 38 (25.3)

Occupation Farmer Student Other

547 (83.4) 220 (95.7) 60 (65.9)

109 (16.6) 10 (4.3) 31 (34.1)

Education level Primary school and below Junior high school Senior high school and above

394 (90.4) 344 (80.9) 89 (76.7)

42 (9.6) 81 (19.1) 27 (23.3)

Religious belief No Yes

628 (83.5) 199 (88.4)

124 (16.5) 26 (11.6)

See alcohol brand names on television Never Sometimes Always

628 (86.4) 177 (81.6) 22 (66.7)

99 (13.6) 40 (18.4) 11 (33.3)

Do you have access to alcohol in your home? No Yes

230 (93.1) 597 (81.8)

17 (6.9) 133 (18.2)

Perceived risk of alcohol drinking on body No risk One risk Two risks Three risks

59 (79.7) 59 (73.8) 370 (83.7) 339 (89.0)

15 (20.3) 21 (26.2) 72 (16.3) 42 (11.0)

Know others’ drinking reason No Yes

684 (86.7) 143 (76.1)

105 (13.3) 45 (23.9)

Friend drinking environment Have no friend drinking environment Have one friend drinking environment Have two friend drinking environment Have three friend drinking environment

198 (99.5) 217 (98.6) 270 (89.7) 142 (55.3)

1 (0.5) 3 (1.4) 31 (10.3) 115 (44.7)

Family drinking environment Have no family drinking environment Have one family drinking environment Have two family drinking environment Have three family drinking environment Have four family drinking environment

100 (93.5) 364 (90.3) 269 (80.5) 81 (72.3) 13 (61.9)

7 (6.5) 39 (9.7) 65 (19.5) 31 (27.7) 8 (38.1)

Levels of acculturation Medium acculturation Low acculturation High acculturation

413 (81.9) 233 (91.4) 181 (83.0)

91 (18.1) 22 (8.6) 37 (17.0)

Current smoking status Non-smoker Current smoker

666 (94.1) 161 (59.9)

42 (5.9) 108 (40.1)

p value <0.001

<0.001

0.037

<0.001

<0.001

0.09

0.005

<0.001

0.002

<0.001

<0.001

<0.001

0.002

<0.001

AUDIT: Alcohol Use Disorder Test.

individuals from consuming, either totally or excessively, psychoactive substances. Taking part in acculturative activities may improve the intense collective life for indigenous people to prevent them from various kinds of misfortunes which may help to reduce alcohol related problems (Currie et al., 2013). An American study showed that participation in universal cultural activities was positively related to alcohol problems while cultural pride was negatively associated with alcohol problems (Yu and Stiffman, 2007).

Chinese traditional culture was dramatically affected by Confucianism, which encourages moderate and moral drinking, yet against frequent and solitary drinking. Drinking is reserved for animal sacrificing, festivals and for showing hospitality to the guests (Hao et al., 2005). Under this culture’s edification, people tend to drink properly and this may explain why more enculturation people tended to have a less risky drinking pattern.

Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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Fig. 1. Relationship between risk level of alcohol drinking and acculturation, religious belief, family and friend drinking environment, and demographic factors. * Parameters in Fig. 1 are standardized value.

The negative association between enculturation and risk perception of alcohol consumption on the body, which was negatively related to the level of risky drinking, and positive association with friend drinking environment, which was positively related to the level of risky drinking, may explain why enculturation was indirectly associated with increased risky drinking. Acculturation in our study showed an indirect positive relationship with risky drinking pattern, which may result from the contribution of friend drinking environment on risky drinking pattern. Increased acculturation means that people contact more friends from other cultures who may influence their drinking behaviors. Religious belief has been proven to be a protective factor from risky drinking in previous studies (Amundsen, 2012; Chaturvedi and Mahanta, 2004; Van Tubergen and Poortman, 2010). Our study indirectly confirmed this. Most religions admonish people for doing harmful things, such as smoking and drinking, to both others and themselves. People who believe in, or practice, a specific religion may have less harmful behaviors, including alcohol consumption. Family drinking environment showed a positive, though small effect (ˇ = 0.062) on risky drinking in this study. Family members are the people contacted most frequently in a person’s daily life. Family behaviors affect their members directly. Adolescents may learn and imitate some behaviors from their parents and older siblings (Beal et al., 2001; Yu, 2003). Likewise, parental expectancy, parental approval, parental modeling, parental monitoring, parent–child relationship quality, parent’s attitude on drinking and so on affect children’s drinking behavior (Newman et al., 2004; Ryan et al., 2010). Apart from family, our study found that people who had more drinking friends tended to have a risky drinking pattern. Previous studies showed that people may change their attitudes or behaviors to match those of their friends (Hawkins

et al., 1997; Newman et al., 2004). Their behaviors may directly affect each other. Peers also have an influence on adolescents through two types of pressure: normative behavior and modeling of behavior (Donovan, 2004; Simons-Morton, 2004). The finding that ethnicity did not show a direct effect on risky drinking may be due to the rapid urbanization in China, causing ethnic minorities to become more similar to the Han majority. However, the indirect negative effect of ethnicity on risky drinking may come from its negative correlation with both family and friend drinking environment. As seen in other studies (Holmila and Raitasalo, 2005; Kuntsche et al., 2004, 2015; Wilsnack et al., 2009), gender was strongly related to risky drinking. In China, drinking and smoking by females are two behaviors considered to be a deviation from traditional cultural values (Ma et al., 2006). Our study confirmed that females consume less alcohol compared to males. Females had more risk perception, and less family and friend drinking environment, which were negatively and positively associated with risky drinking pattern, respectively. Our study also found that perceived risk of alcohol drinking on the body was an influencing factor for alcohol consumption; people who hold the view that excessive alcohol consumption would harm them tended to have a less risky drinking pattern (Bühler et al., 2015; Grevenstein et al., 2015; Henry et al., 2005). Apart from the above mentioned factors, education level and age group in our study were found to have a positive indirect effect on risky drinking pattern. Studies have shown that risky drinking pattern increased with age in adolescence while decreased in adulthood (Liang and Chikritzhs, 2013; Talley et al., 2014; Wolff et al., 2014) and people with a higher education level are more likely to have harmful behaviors such as alcohol consumption (Cutler and Lleras-Muney, 2006; Huerta and Borgonovi, 2010). Our results

Please cite this article in press as: He, J., et al., Disparities in drinking patterns and risks among ethnic majority and minority groups in China: The roles of acculturation, religion, family and friends. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.12.028

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0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.061 0.061 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.352 0.352 0.000 0.000 0.000 0.000

Friend drinking environment Perceived risk

0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 −0.066 −0.065 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.109 0.109 0.000 −0.331 −0.331 0.000 −0.108 −0.108 0.000 −0.322 −0.193 −0.130 −0.532 −0.528 0.000

Gender Age

0.000 0.000 0.000 0.000 0.000 0.000 −0.108 −0.108 0.000 0.214 0.214 0.000 0.087 0.087 0.000 0.088 0.000 0.088 0.218 0.225 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 −0.096 −0.096 0.000 −0.073 −0.073 0.000 −0.038 0.000 −0.038 0.000 0.000 0.000

Religion

0.000 0.000 0.000 0.000 0.000 0.000 0.221 0.221 0.000 0.076 0.075 0.000 0.000 0.000 0.000 0.012 0.000 0.012 0.000 0.000 0.000 0.000 0.000 0.000 −0.072 −0.072 0.000 0.007 0.000 0.007 −0.107 −0.102 −0.005 −0.084 −0.084 0.000 −0.038 0.000 −0.038 −0.135 −0.131 0.000

Enculturation Acculturation Ethnicity

showed that people who had higher education and higher age tended to have a larger family drinking environment and more drinking friends, which may affect their behaviors. Studies have consistently shown that marriage is a protective factor against risky drinking (Bogart et al., 2005; Kearns-Bodkin and Leonard, 2005; O’Malley, 2004), as married people have changed into traditional adult role that disapproves of deviant behaviors (Bogart et al., 2005) and also have less recreational activities with friends (O’Malley, 2004). In our study however, marriage had no significant effect on drinking behavior. Our findings may provide strategies for intervention or prevention programs, for example, inheriting and developing aboriginal culture, promoting religious affiliation, providing effective health education to both adolescents and adults on alcohol consumption related problems, especially in a family environment, reducing accessibility of alcohol in the house and teaching people how to cope with pressures of drinking from friends, colleagues and leaders. Although our results showed reasonable similarities with previous studies both internationally and in China, some limitations should be acknowledged. The nature of a cross-sectional study cannot reveal causal relationships, but can provide ideas for further studies. The VIA does not contain information of cultural participation (Currie et al., 2013), thus future studies could include questions to determine the values and behaviors which influence the level of cultural value and participation. Systematic sampling bias has occurred as the selection of households was not random. However, all consecutive households in the selected township were visited and all eligible respondents in each household were recruited until the required sample size was obtained. This method somewhat minimized sampling bias under such constraint of data collection in a poor area where transportation is often difficult. It should be noted that only 24% of the variance for risky drinking was explained by the abovementioned factors; other possible influencing factors of risky drinking such as biological characteristics, cultural practices and expectancy on alcohol should be included in future studies. Our results support the assumption that enculturation is a protective factor for risky drinking. Although results did not show a direct effect of religious belief on risky drinking, at least they provide a clue that religious belief has an indirect effect on risky drinking. Family and friend drinking environment in our study are possible positive determinants on risky drinking. Other demographic factors (marital status, education level, and ethnicity) also have effects on risky drinking.

Current smoking status

Risk level of alcohol consumption

Family drinking environment

Friend drinking environment

Perceive risk

0.106 0.106 0.000 0.084 0.084 0.000 0.015 0.000 0.015 0.188 0.174 0.014 0.124 0.124 0.000 0.067 0.000 0.066 0.000 0.000 0.000 Total Direct Indirect Total Direct Indirect Total Direct Indirect Total Direct Indirect Total Direct Indirect Total Direct Indirect Total Direct Indirect Enculturation

Education Marriage

−0.129 −0.129 0.000 0.119 0.119 0.000 −0.043 0.000 −0.043 −0.001 0.000 −0.001 0.000 0.000 0.000 −0.007 0.000 −0.007 0.000 0.000 0.000

Effect

Funding

Acculturation

Variables

Table 5 The effects of independent variables on dependent variable (Standardized regression weights, ␤).

0.000 0.000 0.000 0.000 0.000 0.000 −0.092 −0.092 0.000 0.075 0.075 0.000 0.000 0.000 0.000 −0.046 −0.079 0.033 0.000 0.000 0.000

Family drinking environment

8

This work was supported by grants from National Natural Science funds of China (Grant number 71263032) and The Education Department of Yunnan Province (Grant number 2014Z068). The sources of funding had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Authors’ contributions Jianhui He, Sawitri Assanangkornchai and Le Cai designed the study and wrote the protocol. Jianhui He was in charge of data collection. Le Cai coordinated and supervised the whole field work. Jianhui He, Sawitri Assanangkornchai and Edward McNeil completed and interpreted the statistical analyses. Jianhui He prepared an initial draft of the manuscript. Critical revision of the manuscript for important intellectual content were added by Sawitri Assanangkornchai, Edward McNeil, and Jianhui He. Edward

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McNeil also helped the proofreading work and all authors have reviewed and approved the final manuscript. Conflicts of interest None. Acknowledgements This paper is based on data collected by research assistants from Kunming Medical University, China. The head of the Institute of Health Education of Kunming city and Luquan County, and the head of Da Xingdi Town of Lushui County provided great cooperation with the study. References Amundsen, E.J., 2012. Low level of alcohol drinking among two generations of non-western immigrants in Oslo: a multi-ethnic comparison. BMC Public Health 12, 535. Bécares, L., Nazroo, J., Stafford, M., 2011. The ethnic density effect on alcohol use among ethnic minority people in the UK. J. Epidemiol. Community Health 65, 20–25. Bühler, A., Thrul, J., Strüber, E., Orth, B., 2015. Cluster-randomized trial of a German leisure-based alcohol peer education measure. Health Promot. Int., http://dx. doi.org/10.1093/heapro/dav007. Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., Monteiro, M.G., 2001. AUDIT: The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. World Health Organization, Geneva, Switzerland. Bayley, M., Hurcombe, R., 2011. Drinking patterns and alcohol service provision for different ethnic groups in the UK: a review of the literature. Ethn. Inequal. Health Social Care 3, 6–17. Beal, A.C., Ausiello, J., Perrin, J.M., 2001. Social influences on health-risk behaviors among minority middle school students. J. Adolesc. Health 28, 474–480. Bogart, L.M., Collins, R.L., Ellickson, P.L., Martino, S.C., Klein, D.J., 2005. Effects of early and later marriage on women’s alcohol use in young adulthood: a prospective analysis. J. Stud. Alcohol Drugs 66, 729. Byrne, B.M., 2013. Structural Equation Modeling With EQS: Basic Concepts, Applications, And Programming, 2nd edition. Routledge, New York. Caldwell, T., Rodgers, B., Clark, C., Jefferis, B., Stansfeld, S., Power, C., 2008. Lifecourse socioeconomic predictors of midlife drinking patterns, problems and abstention: findings from the 1958 British Birth Cohort Study. Drug Alcohol Depend. 95, 269–278. Casswell, S., Pledger, M., Hooper, R., 2003. Socioeconomic status and drinking patterns in young adults. Addiction 98, 601–610. Chaturvedi, H.K., Mahanta, J., 2004. Sociocultural diversity and substance use pattern in Arunachal Pradesh, India. Drug Alcohol Depend. 74, 97–104. Cheah, C., Nelson, L., 2004. The role of acculturation in the emerging adulthood of aboriginal college students. Int. J. Behav. Dev. 28, 495–507. Currie, C.L., Wild, T.C., Schopflocher, D.P., Laing, L., Veugelers, P., 2013. Illicit and prescription drug problems among urban aboriginal adults in Canada: the role of traditional culture in protection and resilience. Soc. Sci. Med. 88, 1–9. Currie, C.L., Wild, T.C., Schopflocher, D.P., Laing, L., Veugelers, P.J., Parlee, B., McKennitt, D.W., 2011. Enculturation and alcohol use problems among aboriginal university students. Can. J. Psychiatr. 56, 735–742. Cutler, D., Lleras-Muney, A., 2006. Education and Health: Evaluating Theories and Evidence. National Poverty Center, Gerald R. Ford School of Public Policy, University of Michigan. Donovan, J.E., 2004. Adolescent alcohol initiation: a review of psychosocial risk factors. J. Adolesc. Health 35, 529.e7–529.e18. ˙ A., Zˇ emaitiene, ˙ N., Zaborskis, A., 2006. Family time, parental behaviour Garmiene, model and the initiation of smoking and alcohol use by ten-year-old children: an epidemiological study in Kaunas, Lithuania. BMC Public Health 6, 287. Grevenstein, D., Nagy, E., Kroeninger-Jungaberle, H., 2015. Development of risk perception and substance use of tobacco, alcohol and cannabis among adolescents and emerging adults: evidence of directional influences. Subst. Use Misuse 50, 376–386. Hao, W., Chen, H., Su, Z., 2005. China: alcohol today. Addiction 100, 737–741. Hawkins, J.D., Graham, J.W., Maguin, E., Abbott, R., Hill, K.G., Catalano, R.F., 1997. Exploring the effects of age of alcohol use initiation and psychosocial risk factors on subsequent alcohol misuse. J. Stud. Alcohol 58, 280. Henry, K.L., Slater, M.D., Oetting, E.R., 2005. Alcohol use in early adolescence: the effect of changes in risk taking, perceived harm and friends’ alcohol use. J. Stud. Alcohol Drugs 66, 275. Holmila, M., Raitasalo, K., 2005. Gender differences in drinking: why do they still exist? Addiction 100, 1763–1769. Hu, L.t., Bentler, P.M., 1999. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct. Equat. Model. 6, 1–55.

9

Huerta, M.C., Borgonovi, F., 2010. Education, alcohol use and abuse among young adults in Britain. Soc. Sci. Med. 71, 143–151. Huynh, Q.-L., Howell, R.T., Benet-Martínez, V., 2009. Reliability of bidimensional acculturation scores a meta-analysis. J. Cross-Cult. Psychol. 40, 256–274. Li, Jianhua, Zhao, Xudong, 2010. Alcohol drinking and society changing study among ethnic minority groups in Yunnan Province. Shanghai Arch. Psychiatry 22, 440–443. Kang, S.-M., 2006. Measurement of acculturation, scale formats, and language competence their implications for adjustment. J. Cross- Cult. Psychol. 37, 669–693. Kearns-Bodkin, J.N., Leonard, K.E., 2005. Alcohol involvement and marital quality in the early years of marriage: a longitudinal growth curve analysis. Alcohol Clin. Exp. Res. 29, 2123–2134. Kim, H.K., Tiberio, S.S., Pears, K.C., Capaldi, D.M., Washburn, I.J., 2013. Growth of men’s alcohol use in early adulthood: intimate partners’ influence. Psychol. Addict. Behav. 27, 1167. Kuntsche, E., Rehm, J., Gmel, G., 2004. Characteristics of binge drinkers in Europe. Soc. Sci. Med. 59, 113–127. Kuntsche, E., Wicki, M., Windlin, B., Roberts, C., Gabhainn, S.N., van der Sluijs, W., Aasvee, K., de Matos, M.G., Dankulincová, Z., Hublet, A., 2015. Drinking motives mediate cultural differences but not gender differences in adolescent alcohol use. J. Adolesc. Health 56, 323–329. Lee, S.Y., Song, X.Y., 2003. Bayesian analysis of structural equation models with dichotomous variables. Stats. Med. 22, 3073–3088. Liang, W., Chikritzhs, T., 2013. Age at first use of alcohol and risk of heavy alcohol use: a population-based study. Biomed. Res. Int. 2013, 721761. Lucchetti, G., Koenig, H.G., Pinsky, I., Laranjeira, R., Vallada, H., 2014. Religious beliefs and alcohol control policies: a Brazilian nationwide study. Revista Brasileira de Psiquiatria 36, 4–10. Lum, C., Corliss, H.L., Mays, V.M., Cochran, S.D., Lui, C.K., 2009. Differences in the drinking behaviors of Chinese, Filipino, Korean, and Vietnamese college students. J. Stud. Alcohol Drugs 70, 568. Ma, G., Zhu, D., Hu, X., Luan, D., Kong, L., Yang, X., 2006. The drinking practice of people in China. Acta Nutrimenta Sinica 27, 362–365. McKay, M.T., 2015. Parental rules, parent and peer attachment, and adolescent drinking behaviors. Subst. Use Misuse 50, 184–188. Newman, I., Xue, J., Fang, X., 2004. Alcohol use and its risk factors among high school students in Beijing. Chin. J. Sch. Health 25, 385–386. O’Malley, P.M., 2004. Maturing out of problematic alcohol use. Alcohol Res. Health 28, 202. Rothe, E.M., Tzuang, D., Pumariega, A.J., 2010. Acculturation, development, and adaptation. Child Adolesc. Psychiatr. Clin. N. Am. 19, 681–696. Ryan, S.M., Jorm, A.F., Lubman, D.I., 2010. Parenting factors associated with reduced adolescent alcohol use: a systematic review of longitudinal studies. Aust. N. Z. J. Psychiatr. 44, 774–783. Ryder, A.G., Alden, L.E., Paulhus, D.L., 2000. Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self- identity, and adjustment. J. Pers. Soc. Psychol. 79, 49. Simons-Morton, B., 2004. Prospective association of peer influence, school engagement, drinking expectancies, and parent expectations with drinking initiation among sixth graders. Addict. Behav. 29, 299–309. Sinha, J.W., Cnaan, R.A., Gelles, R.J., 2007. Adolescent risk behaviors and religion: findings from a national study. J. Adolesc. 30, 231–249. Talley, A.E., Hughes, T.L., Aranda, F., Birkett, M., Marshal, M.P., 2014. Exploring alcohol-use behaviors among heterosexual and sexual minority adolescents: intersections with sex, age, and race/ethnicity. Am. J. Public Health 104, 295–303. Tang, Y.-l., Xiang, X.-j., Wang, X.-y., Cubells, J.F., Babor, T.F., Hao, W., 2013. alcohol and alcohol-related harm in China: policy changes needed. Bull. WHO 91, 270–276. Tavakol, M., Dennick, R., 2011. Making sense of Cronbach’s alpha. Int. J. Med. Educ. 2, 53. Tumwesigye, N.M., Atuyambe, L., Kibira, S.P., Wabwire- Mangen, F., Tushemerirwe, F., Wagner, G.J., 2013. Do religion and religiosity have anything to do with alcohol consumption patterns? Evidence from two fish landing sites on Lake Victoria Uganda. Subst. Use Misuse 48, 1130–1137. Van Tubergen, F., Poortman, A.-R., 2010. Adolescent alcohol use in the Netherlands : the role of ethnicity, ethnic intermarriage, and ethnic school composition. Ethn. Health 15, 1–13. Weinreich, P., 2009. ‘Enculturation’, not ‘acculturation’: conceptualising and assessing identity processes in migrant communities. Int. J. Intercult. Relat. 33, 124–139. Wilsnack, R.W., Kristjanson, A.F., Wilsnack, S.C., Crosby, R.D., 2006. Are US women drinking less (or more)? Historical and aging trends, 1981–2001. J. Stud. Alcohol Drugs 67, 341. Wilsnack, R.W., Wilsnack, S.C., Kristjanson, A.F., Vogeltanz-Holm, N.D., Gmel, G., 2009. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction 104, 1487–1500. Wolff, J., Rospenda, K., Richman, J., 2014. Age differences in the longitudinal relationship between work-family conflict and alcohol use. J. Addict. 2014, 354767. Yu, J., 2003. The association between parental alcohol-related behaviors and children’s drinking. Drug Alcohol Depend. 69, 253–262. Yu, M., Stiffman, A.R., 2007. Culture and environment as predictors of alcohol abuse/dependence symptoms in American Indian youths. Addict. Behav. 32, 2253–2259.

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