Across the globe, alcohol consumption is the third largest risk factor for disease and disability and causes 4% of all deaths worldwide, which is greater than deaths caused by HIV/AIDS, violence, or tuberculosis (World Health Organization [WHO], 2014). Excessive alcohol use poses risks for people who are in proximity to, or are interacting with, someone using alcohol. Adverse effects for others occur through dangerous actions of intoxicated persons and the deleterious effects of alcohol exposure for fetuses and child development (WHO, 2014). One expression of excessive alcohol use is alcohol use among underage young people (National Prevention Council, 2014). Recent data indicate that, globally, levels of drinking among underage youth are increasing as are levels of hazardous and harmful drinking patterns across age groups (WHO, 2014). In 2010, the World Health Assembly approved a resolution to endorse a global strategy to reduce the harmful use of alcohol across age groups (WHO, 2014). Reduction of underage drinking has been identified as national priorities in the United States and United Kingdom (Public Health England, 2016; U.S. Department of Health & Human Services, 2018).
Results of previous studies can be combined to map the progression of alcohol involvement, from initiation to drinkers with drunkenness, in youth in the United States and United Kingdom (Donovan & Molina, 2013; Maggs, Staff, Patrick, Wray-Lake, & Schulenberg, 2015). Initiation to the use of alcohol may occur via tasting or sipping others' drinks around ages 8-11 years. Data from a longitudinal cohort study in the United States revealed that 37% of 8-year-old children reported having had tasted or sipped alcohol (Donovan & Molina, 2013). After initiation, children move to light drinking at around ages 14-15 years (Donovan & Molina, 2013; Maggs et al., 2015). Light drinking is more than sips from another's drink. Light drinking is defined as having one's own whole drink (i.e., half a pint of beer or cider, one alcopop, a small glass of wine, or measure of spirits) equivalent to 12-14 grams of alcohol (Donovan & Molina, 2013; Maggs et al., 2015). Rates of light drinking increase throughout adolescence. Among children ages 10-11 years in the United States and United Kingdom, 5%-16% reported engagement in light drinking (Donovan & Molina, 2013; Maggs et al., 2015; NHS Digital, 2017). Rates of light drinking in the United States increased to 25% at the age of 14.5 years and 63% by the age of 17.5 years (Donovan & Molina, 2013). Among a sample of youth in the United Kingdom, 73% of 15-year-olds reported light drinking (NHS Digital, 2017). Some young people who are light drinkers will progress to become drinkers with drunkenness. Drinkers with drunkenness is defined as engagement in binge drinking, being drunk, and/or having alcohol problems such as hangovers, blackouts, vomiting or passing out, and negative consequences from drinking such as trouble with parents, with friends, at school, or with police (Donovan & Molina, 2013). In one cohort sample, 3.4% of youth at the age of 13 years, 11.7% at the age of 15 years, and 37.5% at the age of 18 years had adopted drinking with drunkenness behaviors (Donovan & Molina, 2013). More young people remained light drinkers throughout adolescence than those who progressed to being drinkers with drunkenness (55% vs. 37.5%, respectively); still, more than one third of young people had developed problematic alcohol behaviors by the age of 18 years (Donovan & Molina, 2013).
Alcohol use during childhood and adolescence is associated with other risk-taking behaviors such as tobacco and other drug use, education and employment issues, risky sexual behaviors, criminal activity, and violence (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2017). Underage alcohol use (i.e., before bio-neurological maturity) can interfere with normal brain development and increases the risk of developing alcohol use disorders (Petit, Kornreich, Verbanck, Cimochowska, & Campanella, 2013). Postponement of alcohol initiation as late as achievable in adolescence may reduce alcohol use among underage youth and adverse outcomes. Understanding the predictors of initiation of alcohol use among children and early adolescents is limited (Maggs et al., 2015). It is important to understand which factors limit or contribute to the trajectory of young people's alcohol use to more effectively achieve alcohol harm reduction. Thus, the purpose of this study was to explore how social and cultural contexts and influences limited and contributed to the trajectory of alcohol use among young people from the perspective of the youth services professionals involved in alcohol harm reduction. We obtained data from youth workers who work directly with large populations of young people to promote healthy lifestyles and avoidance of health risks. Youth work occurs within voluntary, intentional, and personal communication and relationships. Youth workers provide advice, informal education, and guidance to young people to promote health and well-being and facilitate development of their sense of self, identity, and values as well as their development as social beings in a social world (Youth Scotland, 2018). To accomplish their work with young people, youth workers reflect on the contexts and life stories of their youthful clients and use those reflections to inform their work. In this study, youth workers shared their perceptions on alcohol use among young people and how their perceptions informed their work. Our results provide an exemplar to understand factors that promote the progression of alcohol use in young people and one community's response to limit underage drinking.
METHODS
This qualitative descriptive study was set in a large borough in Northern England. Most of the population (>80%) lived in urban areas made up of separate towns separated by acres of agricultural land. This borough is in the fifth poorest area of northern Europe (Eurostat, 2014).
Protection of Human Subjects
After approval by appropriate university institutional review boards, researchers met with administrators from the youth service to obtain their support for the project. Administrators informed youth workers throughout the service about the study. Interviews were scheduled on 2 days at the main youth center. The interview dates were shared with youth workers. Interested youth workers were permitted to participate in the study during their workday. Researchers were present on their scheduled days. Youth workers who presented for interviews were eligible to participate. Researchers explained the study and obtained informed consent. Names of youth workers who participated were not shared with administrators.
Participants
Eight youth workers from five youth centers participated. The participants were 50% female, 88% White British, and 12% Black African. Four were in the age range of 41-50 years; three, in the age range of 31-40 years; and one, in the age range of 21-30 years. Years of youth work experience ranged from 7 to 24 (M = 13, SD = 6.6).
Data Collection
Data were collected via individual semistructured interviews. Audio-recorded interviews occurred in a private room. They were transcribed verbatim by a professional transcriptionist. Open-ended interview questions elicited perceptions of young people's alcohol use and how those perceptions informed their work with young people (see Table 1).
Data Analysis
Data were analyzed with an inductive process of thematic analysis to identify patterns across participants' accounts and derive themes that described participants' perceptions at an aggregated and abstract level (Braun & Clarke, 2006). To bring order to data and organize the material, one researcher reviewed transcriptions while listening to the taped interview to correct errors, fill in missing passages, and remove identifying data. Reading, rereading, and thinking about the data, the second step of the analysis, occurred throughout the process of data analysis. Transcriptions were entered into NVivo for coding. The coding schema began with a template and included four primary codes: youth centers, youth workers, young people, and young people and alcohol. Three researchers read two transcripts to identify subcodes for each of the primary codes and additional free codes, resulting in a coding scheme that was applied to the subsequent transcripts. Upon completion of coding, data within each code were reviewed and summarized. These summaries were used to search for patterns in the data within and across codes, reorganize data into larger categories, and eventually identify themes and subthemes.
Various methods were employed to limit bias and ensure rigor and confirmability. The small, purposeful sample facilitated a deep exploration of the youth workers' perceptions. Rich and detailed descriptions of the themes and subthemes and participants' quotes were included so readers are able to assess whether these results apply, or are transferable, to other populations. Rich description also depicted the complexity and context of the results, which increases the credibility and accurately captured the participants' perceptions. A detailed account of the methods and limitations was included for transparency regarding the reproducibility and limits of this study. The research team included members from within, and outside, this community. Researchers contributed both insider and outsider perspectives during the data analysis, which helped with reflexivity, the practice of overtly examining one's own biases and preconceptions.
RESULTS
The participants described a hypothetical trajectory of alcohol involvement, which can be understood as a possible pathway for alcohol involvement of adolescents. This trajectory was characterized by the theme "Alcohol is an Expected Part of Life." The theme "Fostering Community in Youth Centers" characterized how youth workers' perceptions of young people's alcohol use informed their work.
Alcohol Use Is an Expected Part of Life
The youth workers in this study perceived that adolescents and adults in their community felt that alcohol use was "an expected part of life." The acceptance of alcohol use as a common practice informed both young people's adoption of drinking behaviors and attitudes as well as adults' responses to teens' drinking.
Part of growing up
Through their experiences, the youth workers felt that young people viewed alcohol use as an expected part of their lives both now as adolescents and in the future as adults. As one female youth worker said, "I think it's become quite well accepted among young people that a night out is drinking alcohol and getting into massive risk taking. Young people see it as part of growing up and as their enjoyment."
Small tight-knit communities
Youth workers described a typical, yet hypothetical, trajectory of alcohol use for young people in their communities. Children under 12 years old were viewed as nondrinkers whose social lives were spent with their families at home. Around ages 12-14 years, young people began to spend more time out of their family homes, socializing in mixed age groups of siblings, cousins, and unrelated peers. In these small, tight-knit communities, young people tended not to travel outside their communities. Groups of young people regularly gathered to socialize and often engaged in alcohol. As one male worker described:
In some of the youth centers I've worked in, 14 & 15-year-olds will hang about with 17 & 18-year-olds in the community because a lot of the communities are very tight knit, and in some ways, socially isolated because young people don't seem to travel a lot because of the cost of travel. They all group in the same parks, in the same areas to socialize. And then when you get groups of young people, invariably, when they're bored, other issues come in like antisocial behavior, alcohol, drugs, etc.
No adult supervision
Young people commonly congregated in places without physical adult supervision and were often out of sight of adults such as secluded areas of parks or inside garages and sheds. One female youth worker explained:
They go to more remote places to have a drink so they don't get caught. Which is when the behaviors start getting out of control, they don't realize how much they're drinking. So it's a problem, that they go further and further away from the village not to be found.
Socialize without consequences
In these youth-only social settings, the younger teens socialized with older teens and young adults who had established alcohol habits and did not temper or defer involvement of the younger teens in alcohol use. A female youth worker said:
They get into using alcohol predominately as a group activity. Because they're with older friends within the community, the access to alcohol is easier for under 13, 14-year-olds because they are hanging around with 17- and 18-year-olds.
Consequently, some younger teens began their drinking careers at the frequency and volume of the older group members. The same female youth worker continued and said:
They might be 12-years-old knocking about with 14, 16, 17-year-old young people. There's such a large age group, because they're brothers, sisters and cousins and things like that, so you end up with a really wide age spread. The older ones [in the social group], that are 16, 17, have drunk once a week for the first four years they were part of the social group. Now they might drink two or three nights a week. But the 12-year-olds are going straight into drinking two or three nights a week 'cause the older ones are.
Youth workers felt alcohol abuse was dangerous for youth of all ages. They perceived the pattern of 12- to 14-year-olds' drinking at the levels of the older group members to be even more dangerous.
Being sociable
Youth workers felt peers did not force each other to drink; rather, the drinkers set the example and peers followed suite: "They get into using alcohol predominately as a group activity," said one male youth worker. Young people drank to be part of the crowd, to be accepted, and to show off. Drinking alcohol was characterized as "the thing to do." One female youth worker stated:
I think they [young people] think it's sociable to drink. I don't think they see any harm in it, and I don't think they recognize any dangers in it. They just think it's okay to do. It's a laugh with their mates. Even if the young people don't particularly like alcohol, they still tend to do it. They think it's being sociable; they think it's good.
Youth workers described how young people perceived benefits from drinking. Alcohol use led to feeling more relaxed and happier, it was a way to respond to stresses of daily life, and it lowered inhibitions, making events or activities more exciting and fun. As one female worker said, "They drink to lose themselves in some sort of way for that night. They want to forget about what's going on through the week or through the day." Youth workers reported hearing young people espouse cavalier attitudes about alcohol use. A female worker participant said:
I think amongst their peers it's all a bit of a big joke really that someone got drunk and they were behaving ridiculously. They sit down and discuss it and they laugh about it. It's all very amusing to them and so they don't really see that as a problem per se.
Adults in community expected youth to drink
Youth workers perceived that alcohol use was experienced by many young people; although youth workers did not condone it, they expected alcohol use to happen. Youth workers also reported that parents expected their children would initiate alcohol use during adolescence. Furthermore, in youth workers' opinions, parents sometimes did things that promoted their children's alcohol use. For example, parents set examples for the normalcy of drinking by drinking themselves at home. A female worker said, "The children witness the parents drinking, so they think it's normal. I think that sometimes leads to the children themselves experiencing, or wanting to experience, alcohol at a younger age, because they see it as normal."
Allowed with limits
Youth workers observed parents allowing their teenagers to drink when they were out with the family or on special occasions such as holidays or Friday nights. Some parents sponsored drinking parties at home as a way to make the drinking environment safer and to put limits on alcohol consumption. When parents bought alcohol for their children and their children's friends, they attempted to limit the amount per person by purchasing the number of acceptable units per day for each child. Parents also attempted to limit alcohol by providing drinks with lower alcohol content like shandy (beer mixed with lemonade). Some parents called the parents of the children who were coming to the party to let them know alcohol would be served and how much would be available for each child at the party. Another way youth workers felt parents contributed to teens' drinking was by giving them money to go out and buy their own alcohol. Youth workers felt teens had ready access to alcohol apart from parents. Alcohol was sold (illegally) to minors from some shops, false identifications were used, and some adults other than parents would buy alcohol for them.
Rules on drinking
Some parents made rules about drinking such as "they'll say they have permission to have a drink but they're not allowed to get drunk." Some parents did prohibit their children from drinking. However, in youth workers' experiences, this prohibition did not stop young people from drinking. As one youth worker reported, "The children who aren't allowed to drink, stay the night at their friend's house whose parents don't mind them drinking." In this way, the children's parents did not know their child was drinking. Youth workers heard young people talk about drinking earlier in the day to hide their drinking from parents. A female youth worker reported, "They drink early in the day, especially school holidays. They'll drink in late afternoon so by the time they go home at nine or ten o'clock at night, they're sober, or sober enough to get through the house and not be questioned."
Youth workers perceived it was typical for young people to initiate alcohol use and to continue the habit into adulthood. Youth workers perceived that adults and young people in the community agreed that alcohol use among young people was an expected behavior. However, in the opinions of youth workers, teens believed drinking alcohol to get drunk was customary, compared with adults who believed having a drink was acceptable but who did not condone drunkenness for teenagers.
Fostering Community in Youth Centers
The primary theme regarding how youth workers' perceptions informed their work was fostering community. Youth workers sought to foster a community within the youth centers by developing services and amenities to attract and engage young people and to cultivate a climate in which young people felt valued, liked, accepted, successful, and safe.
Alternative social setting
The youth centers were places for young people to socialize; be safe and protected; explore their identities; receive information, support, and guidance; and access specialty services such as sexual health clinics, education/school training programs, and counseling. Youth workers facilitated community development with their interpersonal skills and style and how they interacted with youth. One male youth worker said:
It's [the centers] much more intense than just being somewhere where they can come and play pool and table tennis. It's also having a group of adults that advocate for them and can steer them in the right direction without judging or patronizing them, more or less on the same level as the young people.
The community within the youth centers was viewed as beneficial and helpful in contrast to the youth-only communities outside youth centers, where alcohol involvement and other risk behaviors were supported and encouraged. Youth centers offered an alternative to social settings where alcohol was used such as pubs, nightclubs, and private places where young people gathered to drink. A youth worker explained, "The idea is to try to divert them from any risky or unsafe practices. So, we have a safe place in youth center for them to come." Centers were open on Friday nights specifically to offer an alternate place to gather on a traditional "party night."
Dilemma of access to safe place
To specifically protect young people, youth center policies prohibited alcohol and other drugs from being physically on the premises and from being used on premises. Young people who were under the influence of alcohol or drugs were prohibited from being on premises. However, youth workers informally evaluated the extent of the young person's drunkenness to determine whether the young person could come in to the youth center. One male youth worker explained:
There is a no-alcohol tolerance in the building. It's a judgment call a lot of the time because if the young person is the worst for alcohol then, of course, you couldn't let them in the center because it could be potentially a problem. If you can't sense that a person has been drinking alcohol, then I don't really perceive it as a problem, especially when you're trying to steer them away from alcohol.
Youth workers described the no-alcohol policy as resulting in young people avoiding drink before coming to the youth center but then drinking after coming to the youth center or on another night. The no-alcohol policy caused youth to avoid the youth centers when they were drinking as they feared that youth workers would ring up parents and notify them of that their child was drinking. Teens who were drinking or drunk were viewed as vulnerable to injury, assault, and engagement in antisocial behaviors. The workers perceived the youth centers as places where they could keep teens safe. The exclusion policy meant that teens who were potentially in danger could not access this safety.
Barriers for youth centers
The community situated within the youth center included youth workers and young people. Parents who had roles in youth drinking, both facilitating and discouraging, were not included. Nor were teens and young adults who did not attend the youth centers but who were influential in youth drinking. Several barriers to community development with youth centers were described by youth workers. These barriers limited the efficacy of the youth centers to decrease alcohol use or increase safer drinking behaviors among young people. Barriers included location of the centers (too far from home and hard to get to), not having bus fare or transportation, and feeling afraid or unwelcome to travel into unfamiliar communities. When young people became 14-16 years old, they often decreased attendance at the centers. As one male worker said, "When young people get to a certain age, a youth center is seen as a much younger activity. We compete with adult activities or adult-perceived activities like clubbing and things like that. Youth clubs are not seen as cool to young people anymore."
Resistance to harm reduction
Youth workers were concerned about young people's alcohol behaviors, attitudes, and practices. However, they did not express confidence about changing the alcohol behaviors of young people. Rather than promote abstinence from alcohol, which they viewed as unrealistic, they sought to teach safety and risk reduction. Although they did teach risks and consequences of alcohol use (such as dependency, involvement in antisocial behaviors, injuries, sexual involvement, and sexual exploitation) and safer alcohol behaviors, this teaching did not yield changes in drinking attitudes or behaviors. In youth workers' opinions, young people's positive attitudes to alcohol use was a reason for their resistance to harm reduction education about alcohol. One female youth worker explained:
We've got the older ones coming in, they've already started drinking they've already seen their benefits. They've enjoyed aspects of it. Because you can't engage them as well if they'd done it-they may have had some experiences which have been quite positive for them and they don't think of the dangers then.
Although the youth workers believed the youth center communities successfully prevented risk behavior and supported youth development when young people were in the centers, they lamented the lack of influence outside the centers. They delivered education to reduce harm from alcohol use, although they felt young people either ignored the teaching or viewed it as irrelevant or, if they did value it, they still did not enact it.
DISCUSSION
The results of this study depicted an exemplar case to highlight how youth work professionals perceived initiation and perpetuation of alcohol use and how those perceptions informed their work to promote health and wellness among young people. They described a hypothetical trajectory of alcohol involvement that can be understood as a potential pathway to alcohol involvement characterized by the theme "Alcohol is an Expected Part of Life." Youth workers perceived that the acceptance of alcohol use as a common practice influenced the initiation, promotion, and efforts to prevent alcohol use among young people. The theme "Fostering Community in Youth Centers" characterized how youth workers' perceptions informed their work with young people. Creating a sense of community within youth centers was a way to build relationships and engage with young people to encourage participation and youth center attendance as well as adoption of health-promoting behaviors.
One aim of this study was to explore how social and cultural processes supported the initiation of alcohol use among young people. Youth workers in this study described initiation of alcohol among young people at the age of 12 years in groups of peers. In a cohort study, alcohol initiation increased 13% (from 52% to 65%) between the ages of 11 and 12 years, and the likelihood of moving from sipping to light drinking doubled (Donovan & Molina, 2013). Youth workers identified a pattern that was not found in the literature, namely, early adolescents who begin their drinking careers at the levels of the older adolescents and young adults in their peer groups. They reported that being in mixed-age social groups made access to alcohol easy for younger teens. In addition, younger teens copied the risk behaviors of the older peers to fit in with the group. As reported in the literature, some children are introduced to alcohol at the ages of 11 and years under (Donovan & Molina, 2013; Maggs et al., 2015). Although the workers in this study reported that young people began drinking at the age of 12 years, it could be that they were initiated at home at younger ages, and rather than starting at the age of 12 years, they were transitioning to light or problem drinking by the time they were 12 years old. Understanding what is happening within families regarding initiation of alcohol use among children is important information, which is missing from this study.
In this study, easy access to alcohol and positive expectations for alcohol use contributed to alcohol use by young people. Young people's desires to be liked by their peers, to fit in, and to have fun were compelling positive expectations that encouraged initiation of alcohol use. The positive expectations existed at initiation; youth quickly adopted positive attitudes toward alcohol as they gained experience with alcohol use. Positive attitudes about alcohol include holding positive expectations for use and having low expectations that alcohol use will result in harm or negative consequences. Among a nationally representative sample of 10- to 11-year-olds in the United Kingdom, youth with positive attitudes about alcohol were more likely to have had an alcoholic drink, felt drunk, and consumed five or more drinks at a time (Maggs et al., 2015).
Alcohol use can be dangerous for young people (NIAAA, 2017). Children and early adolescents have little life experiences, are new to independence, and have limited capability for abstract thought. They are less skilled at anticipating consequences, making choices, identifying alternatives, and evaluating the veracity and intentions of others. Their immature cognitive development, lack of experience, and desire to fit in make them vulnerable for involvement in risky behaviors and exploitation. Thus, interrupting the trajectory of alcohol involvement to prevent and/or reduce alcohol use among young people is vital.
The age of 8-11 years represents a window of opportunity for prevention. Typically, children under 11 years who hold negative expectations for alcohol use believe that alcohol use can be harmful (Maggs et al., 2015). They are also less likely to have been introduced to alcohol. For children 11 years and younger, delaying alcohol initiation may be an effective way to prevent alcohol-related problems for young people. Delay of alcohol initiation may be achieved with interventions to advocate for children to abstain from alcohol, including sips from others' drinks; reduce positive expectations for alcohol use; and reinforce positive expectations for alcohol abstinence rather than increasing negative alcohol expectations (Jones & Gordon, 2017). There is a view that exposing young people to alcohol will help them learn to drink responsibly. However, researchers have identified an indirect relationship between age of initiation and occurrence of serious consequences of alcohol use such as tobacco, marijuana and other drug use, injuries, academic and employment issues, and criminal and violent involvement (Maggs et al., 2015). The evidence supports that early initiation does not teach children to drink responsibly. Encouraging abstinence from alcohol among children is a prudent means to prevent adverse outcomes of alcohol use.
In terms of harm reduction, ages 12-15 years represent a window of opportunity to deter the transition from sipping/light drinking into more problematic behaviors such as binge drinking, drunkenness, and alcohol problems (Maggs et al., 2015). Not all young people will transition from light drinking to problem drinking; however, a substantial portion do. For example, in a U.S.-based cohort study, the prevalence of binge drinking, drunkenness, and alcohol problems doubled from 14% to 28% between ages 16 and 17.5 years (Donovan & Molina, 2013). It is optimal to help young people avoid adverse outcomes by reducing their alcohol use and ideally preventing problem drinking. In the current study, youth workers felt that, once youth were engaging in drinking with their peers, strategies to promote abstinence from alcohol would not work. They advocated for harm reduction through education regarding safer use and risk reduction and facilitated community to support positive youth development in an alcohol-free setting. Harm reduction may be achieved with environmental interventions to limit access to alcohol such as by raising prices, maintaining a minimum legal drinking age, and zero-tolerance laws for driving after any amount of drinking for people under 21 years (NIAAA, 2017). Prevention of problem drinking may also be supported with interventions to promote positive expectations for light/safe/limited alcohol use and to cultivate alcohol-limited or alcohol-free social settings in which young people can engage in fun, cool, meaningful activities and relationships with other young people. Key aspects of a comprehensive approach for effective alcohol harm reduction include policies and their enforcement, public awareness and education, action by community coalitions, and early brief alcohol intervention and referral programs (Harding et al., 2016).
Limitations
This study included a small sample of participants from one area of the United Kingdom. However, youth workers formally and informally interact and observe large numbers of young people. Thus, the participants in this study formed perceptions about alcohol use in this population based on their interactions and experiences with youth over their careers. The perceptions of young people and parents were missing from this report. Those perceptions are needed to further understand how social and cultural factors influence the trajectory of alcohol use.
CONCLUSION
Alcohol use is common in most parts of the world. Alcohol has significant social, cultural, and ritual applications; it is an important economic commodity and is enjoyed by many people. Still, alcohol use can be problematic for young people and poses unique and potentially severe immediate and long-term consequences. In this study, the themes "Alcohol is an Expected Part of Life" and "Fostering Community within Youth Centers" characterized the experiences of this community as an exemplar from which others may understand the contexts that support and limit alcohol use among young people in their own communities. Practitioners may engage in a range of practices to help youth avoid excessive alcohol use and untoward consequences such as advocacy for alcohol abstinence, harm reduction education, provision of alcohol-free social settings, and environmental interventions.
Acknowledgments
The authors acknowledge the contributions of Dr. Sharron Hinchliff.
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