Perceptions of Alcohol and Alcohol Use among Community Members and Young Adults in Ukraine

Abstract

Background: Unhealthy alcohol use is a public health issue, prioritized by the World Health Organization (WHO) for prevention and reduction. Ukraine falls in the highest WHO category of “years of life lost” due to alcohol use. Objective: To investigate perceptions of alcohol consumption in a sample of youth and adults in western Ukraine. Methods: In-depth semi-structured interviews were conducted with 38 adult stakeholders (aged 21–63 years), and 81 adolescents and young adults (aged 12–21 years) completed paper-and-pencil open-ended questions. A combined deductive-inductive thematic analysis of these qualitative data resulted in an initial coding scheme for both parts of the data. These initial codes were organized into patterns, which were further condensed to four themes. Results: The four themes that were developed are: (1) The general historical, socio-economic-political situation and its relation to alcohol use, (2) Alcohol in the home and daily environment, (3) Alcohol use, related feelings, peers, family, and burden to health, and (4) Perceptions of the consequences of alcohol (mis)use. Conclusions: Respondents indicated awareness that daily consumption, also in youth, as well as binge drinking and childhood sipping constitute a risk to health. These risks were described in the context of easy availability, low pricing, and peer pressure. The respondents mentioned awareness that alcohol dependence (AD) of parents affected families with the risk of disadvantageous child development. Interventions may include targeting current norms, stigmatizing beliefs and supporting subjects in developing coping skills.

Keywords:

• Alcohol dependence
• alcohol related disease and harm
• Ukraine
• norms
• health beliefs
• stigma

Introduction

The burden of non-communicable disease allocated to alcohol misuse occupies the fourth place worldwide (World Health Organization (WHO), 2018). Alcohol misuse has been associated with an increased risk of 200 chronic and acute diseases such as physical disease, mental disease, and consequences of prenatal alcohol exposure (Rehm et al., 2009). Alcohol has equally been implicated in (un)intentional harm, interpersonal violence, and alcohol dependence has been linked to stigma (Rehm et al., 2010; Schomerus et al., 2010). The most detrimental effects of alcohol on health are linked to the quantity and patterns of alcohol consumption and in particular to binge drinking. The highest rate of alcohol dependence (AD) associated with binge drinking are found in eastern European countries (Rehm, Shield, Gmel, Rehm, & Frick, 2013). Ukraine falls in the highest WHO category of “years of life lost” due to alcohol use, with an average alcohol consumption of 13.8 liters of pure alcohol per person per year (WHO, 2018). Legislation prohibits any alcohol use when driving and under 18 years old. There is, however no formal policy e.g. about the manufacturing or sales of alcohol. Consumption of unrecorded alcohol is suspected to be high (WHO, 2018).

Ukraine has a complex history and currently a frozen conflict with Russia, which may affect economic pressures (Haukkala, 2015). It is considered to be a middle-income country; however, 3.3% of the population lives on $5 per day or less and moderate poverty was 22% of the population in 2015 (The World Bank, 2016; WHO, 2018). Alcohol misuse has been linked to poverty and is more common among marginalized populations (Hess, Frohlich, & Calio, 2014; Jones, Bates, McCoy, & Bellis, 2015). Research among young adults in Ukraine showed that especially those with high-risk occupations (e.g. coal mining) reported more frequent alcohol consumption. Increased risky behaviors were associated with coping with anxiety or stress, or reported as a result of social influence (Polshkova, Chaban, & Walton, 2016). Equally, Novikova, Ostafiichuk, and Khandii (2019) raised concern about (the consequences of) social injustice and economic disadvantages for, among others, young and vulnerable people. Furthermore, increased alcohol consumption has also been linked to the quality of parenting (Burlaka, Grogan-Kaylor, Savchuk, & Graham-Bermann, 2017), which affects children’s well-being. Chambers et al. (2014) reported in their large sample of pregnant women in Ukraine that 97% were ever drinkers and 46% of those had consumed alcohol in the most recent month of pregnancy. In Ukraine the age of alcohol initiation is between 10–13 years old (Currie et al., 2004) which constitutes an increased risk for limitations in development, affecting learning and contributing to lower earning potential (Hellemans, Sliwowska, Verma, & Weinberg, 2010; Luciana, Collins, Muetzel, & Lim, 2013; Steinhausen & Spohr, 1998).

In summary, alcohol misuse and dependence may affect the health of the person and their family in a wide array of ways. The purpose of the current study was to make an inventory of perceptions of alcohol use, its relation to health, and whether these perceptions differ between different stakeholders such as youths and adults in Ukraine.¹ Knowledge of these perceptions may ultimately inform the development of interventions.

Methods

Settings and respondents

The research reported here was conducted in rural and urban areas; villages and cities stretching over an area of about 700 kilometers in (south) western Ukraine. This area has a population of Ukrainian, Hungarian, and some Roma, Ruthenean, or Russian inhabitants. We gathered our data in two ways: We conducted semi-structured in-depth interviews with 38 adult stakeholders (aged 21–63 years) from the communities and asked adolescents and young adults (aged 12–21 years) to complete paper-and-pencil open-ended questions. People were invited to participate in the interviews, sampling a wide spectrum of stakeholders; people who misuse alcohol currently, family of person(s) who is (or was) misusing alcohol, health professionals, and people in varying community roles. Respondents reported a range of socio-economic and educational backgrounds from the highest completed level of grade 9 to medical doctor degrees. These roles and positions were determined based on the respondents’ self-reports. For example, we included individuals who stated to have recovered from AD but we did not conduct checks whether this was indeed the case. Some community leaders held (in)formal positions, e.g. a mayor or a medical doctor involved in setting up private clinics.

Due to constraints imposed by pupils’ curricular schedules at schools, we chose to administer semi-structured open-ended questions, which the pupils completed in their classrooms. The packet of questions was printed on paper, and included themes such as the perceptions of (mental) health, perceptions of alcohol use and the relationship between these factors. In constructing these questions, as well as the interview guide, we were guided by theories that attempt to explain behavior, and applied these theoretical constructs to our questions about perceptions of health, legislation, and subjective norms about alcohol (mis)use and alcohol dependence (see e.g. Bartholomew Eldredge et al., 2016). Alcohol dependence (AD) in this study is not a diagnostic term but is used to describe varying levels of alcohol misuse that interfere with daily activities in work- and social life and/or the need to consume alcohol. AD survivor is defined as people who overcame alcohol dependence as defined above. Alcohol misuse is not necessarily AD, and in the current paper we use the term to express the descriptions used by our respondents, for example to indicate binge drinking (Wechsler & Kuo, 2000) or other forms of alcohol consumption that pose a risk to health.

The research ethics committee of the Faculty (the Faculty of Psychology and Neuroscience of Maastricht University, The Netherlands; removed for blind review) approved this study. No compensation was provided to participants, participation was completely voluntary. Levels of informed consent (school management, teachers, parents, children) were obtained from both samples before the data collections commenced (Table 1).

Table 1. Sample composition (Note this table contains frequencies based on self-report).

	Rural	Urban	Age
Interviews
People recovered from alcohol misuse	3	7	18–60+
Male/female	6	4
People at high risk of continued alcohol misuse	1	6	30–55
Male/female	6	1
Family of people misusing alcohol	3	2	20–39
Male/female	0	5
Community leaders	3	3	30–65*
Male/female	4	2
Health Care professionals	2	3	25–59
Male/female	4	1
International volunteers & professionals	5	0	15–60+
Male/female	1	4
Open-ended questions
1 middle school	1		12–21
Male/female	9	8
1 high school	1
Male/female	10	16
1 middle and high school		1
Male/female	9	15
1 college		1
Male/female	6	8

Data collection and materials

In-depth interviews

The first author conducted the interviews. Apart from one visit to one of the villages, there was no prior relationship with Ukraine. International NGOs and international workers introduced the researcher to translators. The researcher approached schools, colleges, and rehabilitation facilities with the help of translators, and approached individuals within these contexts. Some participants were invited from a selection of the population, such as individuals who reported having overcome alcohol dependence. Word of mouth recruitments comprised the main strategy, and often started with translators in the communities asking around for interested individuals. The in-depth semi-structured interviews focused on perceptions of (harmful) alcohol use and its relationship to health in Ukraine, participants’ local communities and their families. Moreover, the interviews focused on lived experience regarding alcohol (mis)use. Each interview lasted about an hour (some 1.5) and was conducted in a prearranged separate room with only the respondent, translator, and researcher present. All interviews were audio-recorded, and translations were once more verified during transcribing the recorded data.

The questions were translated, and participants received a written copy of the interview guide at the start of the interview to inform them about the content and provide them with the opportunity to propose changes. Next, the interviewer introduced the topic and asked the first question, which was simultaneously translated. The written questions served as a guide during the interview, but were utilized sparsely, because the respondents talked freely and spontaneously about their perceptions of and experiences with alcohol. Further explanations were asked or evoked using short prompts “to tell a bit more about an issue.” Example questions are: “What do you see in your environment in relation to alcohol (use)?,” “What do you consider to be ‘healthy alcohol consumption’ with respect to your age group?,” and “What are the disadvantages of alcohol consumption for your age group?”

Open-ended questions

The second sample consisted of middle school, high school, and college students attending the institutes that agreed to participate in the research. The pupils were invited to complete a set of open-ended questions during class. Students completed the questions independently, under supervision of a homeroom teacher, with the researcher being present. No further guidance was given unless the pupils asked questions. Completed forms were handed in face-down, not visible to teachers or the researcher.

The packet for pupils contained ten open-ended questions in total, covering the following topics: students’ perceptions of their own health, healthy alcohol use (given their own age), the law and (inter)national (non-)adherence to legislated alcohol use, peers and alcohol consumption, and their thoughts on the prevention of alcohol misuse. These questions were constructed based on the Reasoned Action Approach, which proposes that attitudinal, normative, and control beliefs influence intentions, which in turn affect behaviors (Fishbein & Ajzen, 2009). Example questions are: What does “health” mean to you? and “If you decide not to join a round of drinks, how would your peers react?”²

Data analysis

The interviews and open-ended questions were analyzed using an inductive-deductive approach (Thomas, 2003). Transcribing ensured the researcher’s familiarity with the data (Braun & Clarke, 2006). Non-verbal information from the interviews was only included in the transcript if deemed different from the speaker’s observed general demeanor, e.g. agitated tone of voice indicated by a higher pitch and pace of speaking. Semantic analysis was conducted next, which concerned the surface meanings of the data without implying meaning beyond the spoken/written words (Braun & Clarke, 2006). All data were analyzed using NVivo 11.

Coding was conducted in two ways: First, some of the codes could be determined a-priori based on the interview protocol and the open-ended questions (e.g. “health” or “alcohol dependence”). Second, the complete data corpus (i.e. both the interview data and the answers to the open-ended questions) was analyzed line-by-line, and a multitude of basic segments formed initial codes that were grouped into larger categories (e.g. perceptions of alcohol use in rural areas, or perceptions of alcohol use and consequences for family members). Thematic analysis was applied to the complete data corpus to identify and organize these initial coding into patterns (which were later condensed in the themes), without further consultation of research or theories, or the questions posed to the two samples of respondents (Braun & Clarke, 2006). For each part of the data (transcripts versus open-ended questions), after initial coding was completed, all materials were again rigorously read, to confirm coding and especially to connect the two sets of data with each other based on the patterns that were generated (e.g. perceptions about health and alcohol use from the interviewees as well as from the adolescents and young adults). The analysis was thus conducted as a recursive process – a constant moving back and forth between the whole data set and the meaning of patterns (and later the (sub-) themes; Thomas, 2003; Braun & Clarke, 2006). A second coder independently coded two interviews and ten student responses to verify the first coder’s scheme. In case of disagreement (i.e. more than 20% on (a) theme(s)) a third independent coder was consulted.

The main aim of these analyses was to reflect reality, i.e. the lived experiences of participants. For example, potential mood disorders, describing behaviors in relation to alcohol misuse (without mentioning the word “mood disorder”) were reported by different groups of stakeholders concerning several family members in a household potentially affected by AD and subsequently reported as risks to health for families. Rather than interpreting these and drawing conclusions about the populations’ mental health, we report these as stated by our respondents.

The four themes that were developed by analysts from the data were: (1) The general historical, socio-economic-political situation and its relation to alcohol use, (2) Alcohol in the home and daily environment, (3) Alcohol use, related feelings, peers, family, and burden to health, and (4) Perceptions of the consequences of alcohol (mis)use.

Results

Theme 1: general historical, socio-economic-political situation and relation to alcohol

Ukraine was described by the respondents as a geographical environment with a variety of natural resources, enough land and a good climate to grow food. Respondents in all professions reported they worked in their own vegetable garden to supplement a low income and/or provide in times of no income. One male community leader (35 years old) observed:

“Teachers did not get paid for a few years.”

Respondents mentioned that many people did not have running water or toilets in their house and had to resort to charity-financed food services in winter. Multiple stakeholders described that people without observable income or bank accounts still manage to get by and they suggested this was a characteristic of a minority in Ukraine. As one female community leader (35 years old) described:

“We know how to live through on thin ice.”

Independence in 1991 was according to community leaders the end of a country that some had not anticipated, because they thought the USSR was the “mightiest” in the world. Following the end of the USSR, in Ukraine several collapses of financial systems ensued accompanied by significant losses of jobs, savings and pensions. Only a few of the respondents mentioned to have anticipated the independence and ensuing chaos and to have redirected their money. Local economies also collapsed resulting in an increased need to become self-sustainable while more people worked on their home farm due to a lack of jobs. Three health workers (males, 35–55 years old) reported this was not full-time work and that:

“… people would drink alcohol the rest of the day … They cannot imagine that they can have a better life.”

Respondents remarked that outdated and still centrally organized political-economic structures affect all citizens in their daily lives from the state of roads, and public transport, to access to medical supplies and the approach to work. According to community leaders some individuals longed for the old days when work and medical aid was certain for everyone and that people in their communities who still work according to communist norms struggle to understand that their work lacks standards in quality and quantity. On the other hand, community leaders, health professionals and international professionals reported about people who successfully made the challenging transition from communism to a free market economy through diligence, hard work and meticulous planning. Community leaders, international workers and an AD survivor described historical habits of payments for local work in (unrecorded) alcohol and reported that nowadays people stopped accepting payment in alcohol and demanded money, which generated sufficient income. However, others go abroad to gain income, which some link to alcohol use in females. An AD survivor (male, 33 years old):

“Here in Ukraine, lot of the men are working abroad, and usually the wife would stay at home with the children. It is a common problem that the wives get together and they start drinking alcohol. Some of them have depression, and if they would drink a little alcohol, she feels better, so she thinks she found herself a medication. … She drinks an amount of alcohol and she is feeling better. This amount would get bigger and bigger. She doesn’t realize that she is addicted to alcohol only her environment realizes it.”

Theme 2: alcohol in the home and daily environment

The next theme that was generated from the data concerns “a culture of alcohol consumption” as a structural part of daily life for many Ukrainians. Respondents mentioned that households grow their own grapes and make their own wine; the vines provide shade for family meals, are accompanied by a glass of wine for all. Being able to make good wine is a rite of passage for males, subject to local competitions and part of family- and cultural celebrations. Wine is consumed throughout the day as if it were water; agricultural workers sip from a small plastic bottle. Sipping in preschool children was reported three times; a female international volunteer (19 years old) doing community visits mentioned:

[Grandmother said] “… a few sips [of wine] does not matter”, and “when she [5 years old girl] liked it, she got a whole glass.”

In contrast, five adults reported their parents taught them abstinence when they were children up until 18 years old.

Community leaders, family members and health workers reported that there used to be a “healthy” culture of alcohol consumption, which consisted of enjoying a drink together, without misuse or binge drinking. They furthermore reported that, much of the current alcohol misuse could be linked to the end of strong state control after the collapse of communism. The majority of the young people however, stated that “healthy” alcohol consumption is not possible. AD survivors, community leaders and students reported that people in Ukraine “do not have control” over their alcohol consumption once they start drinking or “do not know their limits.”

From the interviews it became apparent that perceptions of alcohol use were intricately linked to specific local situations. Lower socio-economic households in rural areas collect drinking water from the local well. Historically it was perceived impolite to serve guests a drink containing water, as one might not be sure about its quality. Alcohol was preferred because it was perceived as “clean.” Furthermore, beer was perceived as the drink to satisfy thirst and it is served at train stations on hot days. Beer is also seen as a drink for young people, females and “weak” people. It is sold in two-liter bottles in local supermarkets and described as cheap compared to beer in Europe. Four male and female AD survivors reported they already regularly consumed alcohol during their early adolescence (18–33 years old):

“I drank beer from 12 years old and regularly from 14 years old.”

The strongest kind of alcoholic drink is vodka (or locally produced equivalents e.g. palinka), perceived as a drink for men and people who are “cool” and “strong.” This labeling of “being cool” was described in more than half of the answers to the questions completed by the youth, and it was in line with the interviews in which adults described alcohol consumption patterns in adolescence. These spirits are made from the leftovers of the fruit harvests or any cheap raw material such as sugar. A yearly harvest celebration of making palinka includes children as reported by an international professional couple (45 years old):

“… it is nice, all taste, including children … 12 to 14 years old.”

Community leaders and older AD survivors state drinking “vodka” is part of a culture that came from the east with (forced) migration or was the result of exposure to extremely strong alcohol concoctions during their one-year conscription. According to a female international volunteer (19 years old) high school boys said:

“We are Russian […] ehm, Slavic culture, we can drink strong alcohol.”

And a male AD survivor said (66 years old):

“And during that time in Russia you could buy those bottles of spirit in a simple shop. And as I got used to drinking wine at home and there in […] I couldn’t drink home-made wine. So, I didn’t like the wine they made, … . And the older soldiers taught me how to drink this spirit, this pure spirit.”

When in company, multiple glasses are quickly consumed, and several AD survivors and community leaders reported having witnessed (or engaged in) excessive binge drinking. A female community leader (60+ years old) said that under communism

“… men drank a lot but were afraid to violate the rules” … “now women drink as much as men.”

AD survivors described stopping school at the earliest possible age (grade 9) and starting to work and that it was normal to consume alcohol before, during and after work. On the one hand Ukrainian customs proscribe that it is rude to refuse a drink, especially from an elder, but on the other hand, once one struggles to cope with the amount of alcohol – and becomes dependent on alcohol - one is shunned by others. A female family member (25 years old) said:

“There is no future if you are alcohol dependent.”

A male AD survivor reported (44 years old):

“… and the people around me did not trust me anymore. It made me feel like I am alcoholic and I do not belong to the society.”

Community leaders reported that they perceived AD in earlier behavioral stages (i.e. going binge drinking with peers after work). They explained that the frequency, type and amount of drinking alcohol might indicate problems. A male community leader (35 years old) reported:

“For our society it is normal to drink two to three times a week, but when you drink vodka like that, it is already alcoholic.”

Interestingly two employers (an international couple and an AD survivor) who reported to have started a zero-tolerance policy on alcohol in their organizations stated few problems in implementing and demanding adherence to the rules. One report from a business in welding stated the need for safety and having dismissed one person over four years. In contrast family members, other AD survivors and international sources reported severe accidents at work.

Another source for daily and easy access to alcohol are local sellers. Family members, community leaders and health workers witnessed children being sent by a parent to local sellers to buy unrecorded alcohol. Local sellers also continued to sell these products, even when customers did not have any money, thus creating financial dependence. One female family member (20 years old) reported:

“They [local producers] even give wine to those who cannot pay in that time … come back then next time you can pay … in almost every village.”

Additionally, respondents reported that youths can also purchase alcohol in shops and clubs. Multiple AD survivors, community leaders and students (in the open-ended questions) report regular alcohol consumption by youths between 12–14 years old. When children and teenagers go out any kind and amount of alcohol can be bought and drinks in clubs (including vodka) are only sold per bottle – increasing the risk of binge drinking. However, some individuals appeared aware of the harm of under-age drinking, since there were community reports of not selling alcohol to children. One female community leader (35 years old) stated:

“If I bought alcohol in the shop they would have called my parents straight away.”

Another community managed to temporarily close the village shop that sold alcohol to children but could not implement lasting change. Some youths reported that in their view alcohol is more harmful to younger children as “their bodies are more vulnerable.”

Theme 3: alcohol use, related feelings, peer groups, families and burden to health

Students and AD survivors reported that alcohol consumption gives a feeling of being “happy,” “free,” and sharing “funny” moments together. A male community leader (35 years old) said:

“I think most of the 12 years old children feel themselves adult when they are drunk.”

Some youths reported to drink alcohol to alleviate stress. Youth, however reported in 44 out of 81 cases that the group would convince them to drink alcohol, if needed forcefully by characterizing the abstainers as “not brave,” “stupid,” “childish,” or laugh at them. Youth reported group responses of stigmatizing and social exclusion:

“… they will look down on me,” and “they will not talk to me,” or “not be friends.”

And a female student (15 years old) reported:

“They will ask you, are you a fool? Why don’t you want to be grown up, to date boys?”

Some youths reported belonging to groups who do not consume or that the group accepts that they do not consume alcohol. About a third of youths linked it to their future goals of studying and reported (sometimes repeatedly) that alcohol use “damages brain cells” and in their perception occurs from a young age. A male student described:

“By the age of 20 they will have been alcoholics with two young children.”

Furthermore, apart from middle school students in a rural area, youth described in increasing detail (with age) that health for them encompasses physical and mental health and some added varying notions of well-being (e.g. social, spiritual; see appendix Table A).

Young people, community leaders, family and AD survivors also linked absent parenting (i.e. “not monitoring”) to children’s daily access to alcohol. Some reported absent parenting in connection to economic pressures (working long hours and/or abroad). A female AD survivor (18 years old) said:

“My parents did not have time to take care of me because they had to work all the time.”

This same female AD survivor reported to start misusing alcohol from 9 years old, telling how her whole room would reek of alcohol the next morning. She said her parents would not investigate after her reply that it was “just beer.” Negligent parenting was in about one third of the youths’ responses linked to parental AD and its consequences, such as a lack of monitoring for their children’s activities, and modeling alcohol (mis)use. Some youths reported that they thought parents need to give their children attention, which was confirmed by three reports from family and survivors. One male community leader who had grown up in an orphanage due to his father’s AD described how parents do not really talk to their children, but are mainly telling them off:

“We do not know how to be families.”

Families, AD survivors and community leaders reported episodes of intoxication and its consequences; deteriorating physical health (i.e. seizures), mental health problems of adults, significant physical violence toward family members, and children taking over parental duties. A female family member of a person experiencing AD (25 years old) stated:

“There is always a house in the street where there is screaming the whole night…,”

“Eight out of ten houses, you think it is normal.”

An AD survivor (male, 60+ years old) reported:

“When I consumed alcohol, we were always arguing with my wife. When I came home drunk, she was very angry with me, of course.”

Suicide and otherwise unnatural deaths were reported five times in this sample and in three cases concerned a first-degree family member. Family members described that the victims experienced AD. One female family member described the moods as being “worst when they wake up” after intoxication. One male AD survivor reported to have had suicidal thoughts before going in rehabilitation. A female family member of a person with AD (39 years old) stated:

“He [father] kept drinking all his life. When he hung himself, he was sober.”

Families experiencing AD were reported to be seen as having a significantly lower socio-economic status (SES), and to experience stigmatization and social exclusion. A female community leader (35 years old) reported:

“It is accepted in our society to look down on them…”

AD survivors and people currently at high risk of misusing alcohol reported after the initial sedative effects of alcohol consumption wore off they would feel “fear,” “shame,” “guilt,” “feeling rejected,” “powerless,” “wanting to forget problems,” and feel that there is no way out, including multiple attempts to stop consuming alcohol and undergoing “inhumane” medical treatment. The latter was reported as “being tied to a hospital bed” and receiving an injection that makes a person feel very sick on consuming alcohol, but its effects were described to wear off over time after which people started to (mis)use alcohol again. However, one male community leader (35 years old) said that men in their culture are not to talk about feelings:

“They only admit they have problems when they are drunk.”

Feelings of “loss” were related to losing jobs, or loss of families or their trust. Family members and community leaders reported extreme poverty, which they thought was directly linked to the need to fulfill cravings for substances, e.g. they reported of individuals spending most of their salary in a binge drinking session with peers.

Successful AD survivors describe after rehabilitation feelings of “happiness,” “belonging,” “peaceful,” “strong,” “wishing a normal life” and “not feeling judged.” A female AD survivor (55 years old) said:

“I could start new things in my life which I hadn’t done before.”

The majority of AD survivors reported that they now understand they cannot consume any alcohol and expressed not to socialize with former peer groups.

Theme 4: perceptions of the consequences of alcohol (mis)use

First, all stakeholders described impairments related to alcohol use during pregnancy in detail. A male community leader (35 years old) said:

“You can see it in their faces.”

Multiple sources reported knowing about alcohol consumption in pregnancy. For example, the youth reported that the dangers of alcohol use in pregnancy were taught to them in high school. Asked about the causes of drinking during pregnancy, multiple sources implicated both the partner and the female. Two females (family members from unrelated families) who preferred to be interviewed together; 20 years old) reported:

“They go [to a bar] because their husband or boyfriend forced them to go,” and “… “if a woman doesn’t experience bad things when drinking alcohol in pregnancy then she will try and do it.”

Health workers, family members and community leaders reported about children born in families experiencing AD and mentioned severe child neglect, orphanage- and state-family placements. Community leaders and health workers reported that they thought some appeared to have children in order to receive financial support (a lump sum paid at birth) and linked such motives to infant abandonment.

International volunteers and family members reported on people marrying young and having children in their early twenties, which they reported would result in unhappy marriages. These perceptions were also linked to views of limited academic success and economic options. In contrast to such perceptions, part of youth and several other younger adults in the interviews reported to prioritize higher education and to abstain from alcohol because of awareness that using alcohol might negatively affect their school performance. A female family member (25 years old) reported that she felt she was not more academically talented than her peers, but succeeded in obtaining a university degree due to her choice of peer groups and her choice not to consume alcohol:

“All do it. Girls in my [middle/high school] class … drink a bottle of wine between three of them in ten minutes … then they go to a disco,” and “it has the image of being cool.”

Multiple sources reported a range of publicly or privately funded higher education options, which are also available for children from lower SES, but might be less so for children with behavioral and/or learning difficulties. A female community leader (30 years old) said:

“If they are not recommended by their pastor they are not allowed to study here.”

About half of the youth reported that in their perception alcohol misuse consequences are not only in a distant future but affect people from early on in life: They described in varying detail behavioral changes, aggressive behavior, and mental- and physical health problems in general and specifically related to young people, such as starting to skip school and having learning problems. For example, according to youth these children from parents with AD:

“They hold the class back,” and they “start to play truant,” and “lying.”

Teachers reported that some students exhibited more severe and persistent learning and behavioral problems. The summary of the results in the appendix reflects the differences between youths (open-ended questions) and adults (interviews).

Discussion

The purpose of the current research was to investigate which factors contribute to alcohol use in Ukraine, which role alcohol plays in Ukrainian society and how the consequences of alcohol (mis)use are perceived by a variety of stakeholders, including youths aged 12-21 years old. Several themes were generated from the semi-structured interviews and open-ended questions.

First, respondents perceived that general factors such as political-economic challenges linked to Ukraine’s complex history and independence in 1991 were perceived as causes for alcohol misuse (Onwijn, 2005). Former Soviet countries, their historical-, geographic-, political challenges and interference with ethnic populations have been linked to structural problems in society associated with e.g. alcohol misuse (Herrick, 2012; Hess et al., 2014). The transition of 1991, as reported in this study resulted for some individuals in a struggle to change one’s outlook on life. However, in contrast to such reports, half of the youth in this sample reported a long-term outlook on their future and making choices that support their plans and goals, including their health behaviors (e.g. not drinking alcohol).

Next, this multi-ethnic sample in Ukraine reported shifting norms concerning alcohol use. Perceptions that it used to be celebratory or people would consider strict public laws appeared changed. Descriptive norms in this sample, that is the unwritten rules in society that most follow (Cialdini, Reno, & Kallgren, 1990), historically reflected a normality of daily and continuous alcohol consumption, but binge drinking was also reported. However, a Mediterranean culture of wine drinking with meals has been associated with the lowest volumes of alcohol consumption of 0.7 liters per person per year in Europe without acceptance of binge drinking (Popova, Rehm, Patra, & Zatonski, 2007; WHO, 2018). This opposes quantities and patterns of alcohol intake reported in this sample. The Ministry of Health of Ukraine did not prescribe a minimum age for the consumption of beer until 2010 (Polshkova et al., 2016), and our respondents reported a custom of consuming beer to quench one’s thirst and of children consuming wine at meal times. One local rehabilitation program instills the routine of consuming tea as a daily drink to quench thirst, including the knowledge about reduced risk to health from boiled water. Some of the norms and drinking habits can be linked to a culture of hospitality, celebrations and being a good Ukrainian citizen. Most respondents expressed limited coping strategies when confronted with such alcohol-related norms in their communities, especially in binge drinking situations or when elders insisted children should participate in celebratory alcohol consumption. These results indicate that alcohol (mis)use prevention need to include strengthening of self-efficacy to resist the pressure from elders and peers to drink alcohol.

Furthermore, a culture and a norm of early childhood access and -acceptance of alcohol consumption, including continuous and easy access (at low prices), was generated in this sample. This is in line with reports stating that in Ukraine 9.3% of boys and 3.1% of girls of 11 years old drink alcohol weekly and first episode of drunkenness was reported at 13.9 for boys and 14.6 years old for girls (Currie et al., 2004). However, given the anecdotal reports of our respondents about children sipping and drinking alcohol at younger ages, the actual age of onset for alcohol consumption might be lower. Research has shown that the age of onset of regular alcohol use is predictive of future problem drinking, other substance abuse, and developmental challenges (Hession, 2012; Hingson, Heeren, & Winter, 2006). Also, that the mental schemata that children form in the first few years of life such as parents’ favorable attitudes about alcohol use and (early) childhood consumption predict childhood alcohol consumption onset (Donovan & Molina, 2007; Zucker, Donovan, Masten, Mattson, & Moss, 2008).

Moreover, the ability to deal with heavy irregular (binge) drinking was reported in this sample as a sign of “strength.” These consumption patterns of consuming vodka or other spirits are associated with northern Europe and/or Slavic cultures and found to be most detrimental to health (Popova et al., 2007). In our sample, the AD survivors reported lengthy denial and a general underestimation of being at risk of becoming addicted as well as denying the supposed dangers of drinking large quantities of alcohol. Importantly, these patterns were associated with men, while Ukrainian men are not supposed to talk about their feelings. Thus, the negative emotive states and consumption of alcohol “to forget” indicate a limited ability to cope with stressors among men. The manner in which people deal with stress and/or anxiety has been linked to susceptibility of AD (Sinha, 2009). Alcohol consumption was linked to lower satisfaction with the quality of the relationship between males and females and the risk of alcohol use in pregnancy (Bakhireva et al., 2011). Burlaka et al. (2017) found that 81% and 58% of Ukrainian women with school age children reported psychological or physical violence respectively from an intimate partner. This was associated among other factors with maternal lower level of education and unemployment in line with this sample’s reports.

Likewise, disadvantageous parenting styles (i.e. inconsistent parenting), as described in this sample have been linked to alcohol use in adolescents (Barnow, Schuckit, Lucht, John, & Freyberger, 2002). In this study alcohol use by youths was reported to reduce stress, which appear in line with literature on psychological distress (i.e. anxiety, depression) among 13–15 years old adolescents in developing countries (Balogun, Koyanagi, Stickley, Gilmour, & Shibuya, 2014). Reports from this sample showed potentially multiple sources of stress for youths, i.e. parental AD, which may be associated with other (undiagnosed) mental problems (Hasin, Stinson, Ogburn, & Grant, 2007). Furthermore, stigma attached to a family AD background as exhibited in general in this sample and by teachers and peers specifically, has been identified as a major source of stress for the person concerned (Bos, Pryor, Reeder, & Stutterheim, 2013). Other adolescent challenges reported in our sample were peer pressure on non-consuming youths, which might be a response to possible limitations (i.e. exclusion) of future options such as access to a good high school or college due to limitations in academic results and/or behavioral problems. Alcohol consumption may serve ascertaining one’s status in a group. Indeed, a limited education may be linked to the lower SES of an AD family background or “working the land,” which was mentioned by some respondents. A significant body of research shows the detrimental effects of adolescent binge drinking on brain functions, but cause and effect relations remain very difficult to establish (Luciana et al., 2013). A poorer neurocognitive performance (e.g. memory, attention, inhibition) was found in adolescents who meet criteria of exposure (Jacobus & Tapert, 2013; Ware et al., 2015). Youths’ reported learning differences in class coupled with reported perceptions of peers that struggling learners limit class progress, warrant the question whether children with learning difficulties need (more) adapted school programs?

Thus, to sum up, the broader patterns from these data point toward a combination of norms and common behaviors - acceptance of alcohol consumption, not talking about emotions, inter-relational violence – and limitations in adaptive coping skills to deal with feelings of anxiety, stress, and depression, and to resist peer pressure and to inhibit certain impulses. Together these may result in significant alcohol related health problems. Some children in the current sample appear at high accumulative risk for AD through these environmental- but also due to several biological factors. Some children face a developmental trajectory which includes prenatal alcohol exposure and its resulting effects on (mental) development and continue to early tasting of alcohol, and being subject to stigma if one comes from an “AD family.” Such factors may put youth at risk for having to accept low-paying, high-risk jobs (Polshkova et al., 2016). Motives for alcohol consumption were reducing stress and anxiety, following friend’s examples and to increase self-esteem.

Interestingly, in our sample successful people and families – that is those who have attained higher educational levels and/or successfully recovered from AD - report clear limitations in alcohol use or abstinence, building and maintaining relationships that sustain and enhance (Fiorillo & Sabatini, 2011) and steadily working toward their goals. Importantly, half of youths reported varying notions of mental health as part of their concept of self and health. AD survivors for example, reported learnt coping skills and emotional well-being, which some described as a feeling of “strength.” Successful people reported making protective choices for themselves and their environment, i.e. children are not allowed to sip alcohol or AD survivors choosing peers who understand their problems. Importantly, half of the youths reported knowledge and awareness of having to limit alcohol intake to achieve desired outcomes in life. Several respondents whose background showed multiple of the discussed risk factors report these protective (for some novel) choices, which might accumulate to reduce risk, resulting in advantageous life outcomes.

Limitations

This was a cross-sectional study in rural and urban (south) western Ukraine, which prohibits causal inferences. The diversity of the sample resulted in a detailed description of alcohol consumption, perceptions of alcohol (mis)use and relations to health. However, the depth and breadth of alcohol misuse needs to be quantified in order to be able to generalize these findings to the larger Ukrainian population and to start addressing alcohol related health problems. There may be selection bias as word of mouth recruitment in communities started with translators (thus naturally their contacts) and the snowballing pattern was not analyzed (Biernacki & Waldorf, 1981). However, the sample ranged from middle school to medical doctor degrees as highest level of education and contained a variety of stakeholders.

Next, other poverty related factors affecting development and quality of life, or which may interact with the variables we investigated cannot be excluded, e.g. effects of nutritional deficiencies on cognition, or daily stress of socio-economic uncertainty. Future research should include these.

Conclusion

Alcohol misuse in historically complex geographical locations has been associated with structural problems such as access to clean drinking water, work, continued education for vulnerable groups, access to sufficient and appropriate rehabilitation programs, policy on alcohol pricing and availability, classifying of alcohol (beer), and unrecorded alcohol. Targeting unregistered artisan home-production (e.g. wine) poses the challenge of its central role in local cultural traditions and might benefit from a reward system for registration (Lachenmeier, Taylor, & Rehm, 2011).

Some of the main themes in this research confirm that people’s underlying beliefs determine their (health) behavior, which accordingly need to be targeted in health promotion interventions (Bartholomew Eldredge et al., 2016). Knowledge in turn has been associated with these beliefs. Despite reported observational knowledge of devastating long-term outcomes of AD and/or alcohol misuse, in the current sample a lack of awareness of the effects of alcohol on one’s body, a fetus, or young children’s brains, the risk and consequences of binge drinking, and the susceptibility and risk of developing AD became evident. Importantly, the notion of control over one’s health in a preventative manner appears to be comprehended by a small segment of this sample including part of youths. Similarly, one can only take care of one’s mental health if there is an understanding what it is and if one feels self-efficacious to influence it (Bartholomew Eldredge et al., 2016). The use of alcohol as a coping mechanism may indicate a lack of self-efficacy. A willingness and readiness to start discussing emotions may be further targeted with motivational interviewing techniques (Murphy, Dennhardt, Skidmore, Martens, & McDevitt-Murphy, 2010). However, this needs to be accompanied by potential solutions which might be the individual’s awareness that coping strategies can be learnt (Bartholomew Eldredge et al., 2016) and creation of platforms for learning these skills. Equally, both individual and structural interventions are needed for male mental health given the extent of suicides reported in this sample alone, the perceived link to AD, reported interpartner violence and proposed effects on the mental- and physical well-being of children. Mental health services for several at-risk groups (such as female victims of intimae partner violence) in this sample are equally important. Similarly, targetting adolesecent’s coping strategies and self-esteem may benefit this target group. Indeed, coping skills and enhanced self-esteem were proposed by Polshkova et al. (2016) as targets for intervention to reduce risky behaviors and alcohol consumption to ease anxiety and stress in Ukrainian youths. Targeting adolescents could work preventively, i.e. the potential to link new coping strategies to advantageous parenting styles.

However, much of the above may have little effect as society’s stigmatizing beliefs have been shown to form a major source of psychological distress, a barrier to seek help and causes of self-stigma (“to become like father”; Bos et al., 2013). This would require changing public perception, while simultaneously strengthening self-efficacy and self-esteem of the subjects of stigma (Schomerus et al., 2010). Perceptions of stigma are reported in an accompanying article.

Declaration of interest

The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.

Notes

1 Stigma related to alcohol dependence in this sample is reported elsewhere.

2 For the complete question list and brief overview of responses from the pupils, as well as matched responses from the interviews, see Appendix Table A.

Appendix

Table A. Open-ended questions and interview findings.

Open-ended questions	Response examples/categories open-ended questions	Matching responses from the interviews
What is health?	Not being sick Physical health and healthy choices/habits Physical and mental health and seeking well-being (e.g., balance)	Healthy means not being sick State health care and guaranteed work under communism No money, no treatment Outdated health system and distribution of resources Healthy means working on the home farm and little vision on a different future. Rehabilitees detail their new routines
What do you do to stay healthy?	Not doing “bad” things, avoiding bad habits, not consuming alcohol or substances Good habits such as healthy food and sports Don’t know, not much	Alcohol does not affect me Old men are addicted after years and years of alcohol misuse Not consuming alcohol There is no work, periods of no income, life is hard here, lost savings in another economic/political transition Leaving school from grade 9, work, drinking with peers (before and after work) Work far from home, parental absence, alcohol consumption using irregular pay Unrecorded alcohol sold on “credit” – cycle Extensive reports of alcohol related illness, acute events (seizures), family violence, work loss Reports of community help for affected families, looking after the children
What is healthy alcohol consumption for your age group?	Healthy alcohol consumption does not exist, alcohol is always unhealthy At my age no one should drink alcohol Unfortunately, lots of kids consume alcohol I consume alcohol and the games we play are fun Three times per week, 100 grams, special occasions/celebrations
The minimum legal drinking age in many countries (including Ukraine) is 18. What do you think about that?	That is good, when you are 18 you can decide yourself There is no age at which alcohol consumption is ok No one adheres to this law, it is a problem of this country. But club owners cannot know the age of children when they sell spirits.
Research world-wide shows that the average age for first drinking alcohol is 12. What do you think about that?	Many young people including 12 years old, consume alcohol and they make the class fall behind Anyone can buy any amount of alcohol Alcohol consumption at 12 years old is own responsibility/kids try/parents fault/society’s fault	Hidden alcohol use among young and females. Once a person shows problems with alcohol use they are “excluded” from society Adults in rehab detailed alcohol consumption habits established from 11 years old.
When in company, do you drink, and why do you drink?	I do not consume alcohol and neither does my group I try not to consume alcohol but my peers / family make me (cannot refuse an elder e.g., when offered or on special celebrations) A glass of wine with lunch	Tradition, celebrations, continuing to consume at home alone, no regulation after the fall of communism. People just drink, they do not enjoy/be a family. Used to be polite: offer guest a clean drink (alcohol) instead of [unclean] water from the well
If you decide not to join a round of drinks, how would your peers react?	I do not consume alcohol and my peers accept that/they do/do not consume I do not want to consume alcohol but they will keep going until I do (“Are you a baby,” “not be friends,” “give me the look”). Not be friends anymore I avoid friends/going out Combination of 1 and 4 and reporting long term goals of education in half of the pupils’ responses.	The boyfriend makes the pregnant girl drink alcohol because he cannot be seen consuming alone. Secret female group that comes together in village x to consume alcohol. “Whispering” in hospital concerning alcohol related illness, especially in women. Women cannot be seen to consume alcohol in public. Binge drinking and drunkenness is “cool,” “adult,” accepted for men. Rehabilitated adults avoid “old” peers.
What are the disadvantages of alcohol consumption for your age group?	Brain damage and many physical problems (e.g., liver). Alcohol “poisons body” and “kills brain cells.” Lying, skipping school, lose morals Will become addicted soon Young bodies cannot cope with alcohol I do not consume alcohol	Disadvantages only show in old age. Disadvantages show in babies, affects women more strongly than men, risk of addiction from young adulthood. No consumption in pregnancy, doctors say a small amount is not harmful.
What can be done to promote healthy alcohol drinking habits for your age group?	TV must stop showing the happy image of alcohol Parent’s fault, they do not watch their children and set poor examples themselves. Teachers are also at fault. Society is to blame, I do not know what can be done Kids try, that is normal Healthy alcohol use is not possible	Beer not classified as alcohol by government Provided at station on a hot day Perceptions: Beer is for “weak” people, strong alcohol is “cool.” Not only punish kids, be families Education, rehab centers, support groups