key: cord-0744519-mzqjli8s authors: Park, Yu Shin; Jung, Yun Hwa; Park, Eun-Cheol; Shin, Jaeyong title: Association between perceived decline in family income due to COVID-19 and alcohol consumption among Korean adolescents date: 2022-02-23 journal: J Affect Disord DOI: 10.1016/j.jad.2022.02.051 sha: 7778e35d2f4d55416c8880cb3f6351be7e80169f doc_id: 744519 cord_uid: mzqjli8s BACKGROUND: This study examines the relationship between the perceived decline in family income due to COVID-19 and alcohol consumption among Korean adolescents. METHODS: Korea Youth Risk Behavior Web-Based Survey 2020 data were used. The study included 42,922 participants (20,672 males; 22,250 females). Multiple logistic regression estimated the relationship between the decline in family income due to COVID-19 and drinking (yes or no) and alcohol-induced blackout (yes or no) status among Korean adolescents. RESULTS: Adolescent males who perceived worsened family income due to COVID-19 had a higher OR for drinking status and alcohol-induced blackout within 30 days (drinking status: OR 1.27, CI 1.15–1.42, alcohol-induced blackout: OR 1.60, CI 1.19–2.15). Females had a higher OR for current drinking (OR 1.22, CI 1.09–1.38). 7th grade females and 10th grade males were more likely to drink alcohol when their household income decline, compared to high school students (10th grade male: OR 1.54 CI 1.18–2.00; 7th grade female: OR 1.57 CI 1.08–2.27). The male group perceiving family financial loss were likely to have an increased frequency of drinking within 30 days (1–9 days: OR 1.26 CI 1.11–1.42, 10–19 days; OR 1.70 CI 1.22–2.36 over 20 days; OR 1.74 CI 1.15–3.09). LIMITATIONS: Cross-sectional design and self-reported data are the main limitation of our study. And the cut-off points for drinking status and heavy drinking factors may be difficult to generalize our findings to different population. CONCLUSIONS: A significantly positive association of perceived decline in family income due to COVID-19 with increased risks of alcohol consumption was observed among Korean adolescents of both sexes. 7th grade females and 10th grade males were more likely to drink alcohol when their household income changed, compared to high school students. Further, adolescents who perceived family financial loss had an increased frequency of drinking. COVID-19 caused a global pandemic, and the World Health Organization (WHO) declared a public health emergency of international concern. 1 In addition to a public health crisis, the pandemic has also had a massive socioeconomic impact. The Organisation for Economic Co-operation and Development (OECD) expected the global real GDP to reduce by 4.5% in 2020 compared to 2019; Korea's real GDP was expected to decline by approximately 1%. 2 The number of new applicants for unemployment benefits increased from 95,584 December 2019 to 211,818 in January 2021, and the amount of benefits reached a record high of about 1 trillion won in Korea in February 2021. 3 To deal with the pandemic, all OECD member countries introduced social distancing and complete lockdowns, thereby impacting incomes and expenses of families, as well as exacerbating poverty and wage inequality. 4, 5 Family financial insecurity due to the COVID-19 pandemic caused an acute threat to the well-being of children and families. 6 Parental economic hardship is strongly related to parents' depressive symptoms, stress, and negative interactions with children. 7 In addition, each patient's unstable childrearing behaviors adversely affected adolescent development. 8 Moreover, worry about family economic hardship is strongly associated to the adolescents' perceived health, though their own relative economic deprivation also plays a significant role. 9 The COVID-19 pandemic has impacted the lives of adolescents in various ways. It has resulted in chronic and acute stress, concern for their families, unexpected bereavements, sudden school break, home confinement in many countries, increased access to the internet and social media, and concern for the economic future of their family and country. [10] [11] [12] Also, in response to COVID-19, a record number of children did not attend school because of the J o u r n a l P r e -p r o o f Journal Pre-proof mandated closures. 13 During this period, students were offered online, self-directive learning materials. 14 Such a social isolation can result in mental problem like irritability, acting out, depression. 15 Another problem during COVID-19 is substance abuse in adolescents. Some studies on substance abuse in adolescents found that the relative frequency of alcohol use increased during the COVID-19 pandemic. 16, 17, 18 Furthermore, one in ten teenagers is still consuming alcohol in Korea, 19 despite the Youth Protection Law, which bans alcohol sales to adolescents under the age of 19. Thus, alcohol continues to remain accessible to this vulnerable population. 20 Korea experienced several waves of COVID-19 infections. Research on the probleminduced response to COVID-19 is necessary because preventions, such as social distancing, can cause serious social problems. To the best of our knowledge, no study has examined the alcohol use of adolescents during the COVID-19 pandemic. Previous studies did, however, consider the gender difference of alcohol use and drinking motives. 21 22 23 To fill this research gap, we focus on the differential effects of the pandemic on adolescent alcohol use, stratified by gender, particularly concerning the perceived decline in family income during this period. This cross-sectional study used data from the 2020 Korea Youth Risk Behavior Web-Based Survey (KYRBWS), conducted by the Korea Centers for Disease Control and Prevention (KCDC). These data were collected from August 3 to October 13, 2020 for classified as 'no' drinkers. Finally, those who checked '1-2 days per month', '3-5 days per month', '6-9 days per month', '10-19 days per month', '20-29 days per month', or 'everyday' were classified as 'yes' drinkers. alcohol-induced blackout was evaluated through the following question. 'In the last 30 days, how many days have you drank until you lost consciousness or suffered alcoholinduced memory loss?"' This 'blackout' represented an additional result of binge drinking. 25 Those who checked 'Not in the last 30 days' were classified as 'no' drinkers. Those who checked '1-2 days per month', '3-4 days per month', and 'over 5 days per month' were classified as blackout drinkers. The main independent variable was: 'Do you think COVID-19 has made the financial condition of the student's family more difficult than before?' The four nominal answers were divided into two groups: one group comprised adolescents who checked 'Strongly agree or agree'; the other group comprised those who checked 'Strongly disagree or disagree'. We also controlled sociodemographic characteristics as follows: grade (7,8,9,10,11, and 12) , subjective academic level (low, middle, high), and school type (mixed-sex school, single-sex school). The socioeconomic factors included parent's education level (middle school or below, high school, college or above, unknown), region (metropolitan, city, rural), household income (high, middle, low), smoking (yes or no), and perceived stress (yes or no). To confirm the association between the perceived decline in family income due to COVID-19 and alcohol consumption, the covariates were compared using the chi-squared J o u r n a l P r e -p r o o f Journal Pre-proof test. All analyses were conducted by sex to examine sex-specific differences in alcohol consumption and family economic hardship. Multiple logistic regression analysis was performed to evaluate the relationship between perceived financial loss and drinking and blackout-drinking status. Multinomial logistic regressions were used when the dependent variables contained more than two categories. The results were reported using odds ratios (ORs) and confidence intervals (CIs). Model fitting was performed using the PROC SURVEYLOGISTIC procedure and application of cluster and strata. The data were analyzed and further stratified by sex using SAS 9.4 (SAS Institute Inc; Cary, North Carolina). Statistical significance was set at P<0.05. Adolescents who consumed alcohol within the last 30 days included 2,340 (11.3%) males and 1,975 (8.9%) females. Among these, 218 (1.1%) males and 240 (1.1%) females drank until they experienced a loss of consciousness or suffered alcohol-induced memory loss during these 30 days. grade, male was more positively associated with alcohol consumption than for middle school students, when comparing students who did not perceive a family income decline (current drinking in grade 10: OR 1.54 CI 1.18-2.00, grade 12: OR 1.27 CI 1.02-2.58); in 7 th grade, being female was more positively associated with alcohol consumption than in high school students, when comparing students who did not perceive a family income decline (current drinking in grade 7: OR 1.57 CI 1.08-2.27). In this study, we investigated the association between adolescents who perceived family income decline and their drinking status and blackout drinking by using nationally represented survey data. Adolescents who believed their household income had worsened had a higher association with drinking status as well as blackout drinking. Our findings, consistent with the results of prior studies, demonstrate a higher likelihood of alcohol use among adolescents with family income decline. 26, 27 Adolescents from economically unstable households may suffer more behavioral and mental health problems. 28 30 Contrarily, other studies showed that the unemployment rate is not linked to alcohol use among adolescents. 31 Experiencing an economic crisis did not increase alcohol consumption. This can be explained from three perspectives. The first is affordability and accessibility. Owing to the low price of alcohol in South Korea-a bottle can be sold for as low as two dollars-adolescents can afford it easily. Further, owing to 24-hour convenience stores selling alcohol, it is easier for adolescents to purchase alcoholic beverages. Regular drinking leads to binge drinking and alcohol dependency for adolescents, aspects that are deeply linked to J o u r n a l P r e -p r o o f Journal Pre-proof accessibility and ease of purchase. The second is that, in our study, the variable concerning the decline in family income was subjective, and did not measure the actual family income. In other words, the actual economic level of individuals who perceived a decline in family income may be high. The third is that, in Korea, under the Youth Protection Act, sellers are punished for selling alcohol to teenagers under 19 years. However, the law does not directly stipulate the restrictions applicable to adolescents who purchased alcoholic beverages. 32 Thus, the drinking age restriction may not be effective in preventing adolescent alcohol-use. The COVID-19 pandemic is a unique situation, requiring such measures as social distancing to curb the spread of the infection. Many adolescents have spent a significant amount of time with their families, waiting for the spread of COVID-19 to decrease. 33 Exposure to alcohol consumption in the family can be both a risk factor and trigger for adolescent substance use. In South Korea, parents are the main suppliers of alcohol. 34 Parental alcohol consumption at home was found to increase the exposure of children and adolescents, as they can drink with ease. 35 Additionally, some studies showed that the perceived availability of marijuana and alcohol declined during the COVID-19 pandemic. These results demonstrate the substantial challenges facing a supply-side approach to reduced adolescent substance consumption. 36 However, this phenomenon is unlikely to occur in Korea, as it did not impose a lockdown policy and stores remain open. In our study, compared to no perceived economic stress, perception of a decline of family income was found to be linked to alcohol-use. In this category, 7 th grade females and 10 th grade males indicated most alcohol use. This may be linked to the fact that the period of puberty for girls is usually experienced earlier than boys. In a previous study, substance use and misuse rarely occurred before puberty. 37 Moreover, the interplay between parentchild J o u r n a l P r e -p r o o f relationship and on-time pubertal boys' and girls' alcohol use was found to be crucial in a previous study. 38 Adolescents with alcohol use have an increased risk of social problems and suicidal behavior. Adolescents with depressive symptoms are more likely to have unhealthy patterns of consuming alcohol. Severe depressive symptoms are associated with more frequent consumption and intoxication. 39 Further, teenage drinking is linked to increased risky sexual activity. One study found that sexual activity after drinking was more associated with binge drinking than normal drinking. 40 In a study on the sexual behavior of college students, experience of rape was significantly higher in female binge drinkers than normal drinkers. 41 The current findings recommend the need for continued alcohol control efforts during the COVID-19 pandemic, restricting youth access to alcohol and supporting prevention. The current study has certain limitations. First, it was based on data from a crosssectional study. Therefore, though associations could be confirmed, causality could not be evaluated. Second, our study relied on self-reported data. Hence, the measurement of household financial loss might not be accurate. Future data and research are required to fully discern the impact of the pandemic on a new generation of adolescents. Future studies will also need to perform precise measurements of actual household income. Third, as the cut-off points for drinking status and heavy drinking factors were adopted from the KYRBWS, it may be difficult to generalize our findings to different settings or populations. 42 Despite these limitations, this study has several strengths. We used the most recent, nationally representative database to determine the association between perceived family J o u r n a l P r e -p r o o f income loss and the risk of alcohol consumption in adolescents. Therefore, the results obtained are highly representative of healthy South Korean adolescents. A significantly positive association of perceived decline in family income due to COVID-19 with increased risks of alcohol consumption was observed among Korean adolescents of both sexes. 7 th grade females and 10 th grade males were more likely to drink alcohol when their household income changed, compared to high school students. Further, adolescents who perceived family financial loss had an increased frequency of drinking. 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Eun Cheol Park and Jaeyong Shin encouraged Yu Shin Park to investigate 'Association between perceived decline in family income due to COVID-19 and alcohol consumption' and supervised the findings of this work. And no funding was received for conducting this study. All authors discussed the results and contributed to the final manuscript.