Prevalence, Reasons, Predictors, Perceived Effects, and Regulation of Alcohol Use among Children in Ghana

Early initiation of alcohol consumption increases the risk of alcohol dependence and adverse health outcomes. Consequently, nations have enacted laws to make alcohol unlawful to be purchased by, sold to, or used in public by children. This study examined the lifetime prevalence of alcohol use among children and their reasons for consuming alcohol. In addition, the study investigated predictors of alcohol consumption and the effects of alcohol use on children. Finally, it examined the effectiveness of measures in place for regulating the sale and use of alcohol by children in the country. A total of 5024 children between the ages of 8 and 17 were sampled across the ten regions of Ghana using a cross-sectional convergent parallel mixed method. Children were interviewed with a semi-structured questionnaire, while focus group discussions were held with children, parents, and key informants. Lifetime prevalence of alcohol consumption was measured by “have you ever taken alcohol?”. The study revealed that lifetime alcohol consumption was less prevalent (6.6%) among children. Sex, age, and region of residence were significant predictors of lifetime alcohol use among children. More than half of the children who reported ever taking alcohol were first introduced to drinking by friends, and more than six in ten children claimed having been intoxicated after drinking alcohol. The findings further revealed that efforts to control the sale and consumption of alcohol by children have proven difficult despite the existence of laws, policies, and national regulatory structures. While regulations on alcohol sales and consumption have been difficult to implement in rural areas, they have been successful in urban areas because institutions there ensure rigorous adherence to the regulations. The study encourages national organizations with responsibility for child protection and development to step up their regulation, investigation, and information-sharing efforts to discourage and limit children from purchasing and consuming alcohol.


Introduction
When a person drinks alcohol while under the legal drinking age, it is referred to as underage drinking. Early alcohol usage is linked to future dependency, health problems, and poor ability to interact with others [1]. Globally, about three in ten (26.5%) children between the ages of 15 and 19 have been estimated to have ever consumed alcohol [2].
In several nations, alcohol use starts before the age of 15; hence, some nations have passed laws making it illegal for children (persons under the age of 18) to buy, sell, or consume alcohol in public [2,3]. Ghana is among the nations with legislation prohibiting the consumption of alcohol by children. Te Liquor Licensing Act of 1970 (Act 331) establishes an age limit of 18 or older for alcohol consumption in Ghana [4]. To regulate alcohol usage and fght underage drinking nationwide, Ghana's government also established the National Alcohol Policy and the Narcotics Control Board (NACOB).
Oshodin [5] highlighted that males were more likely than females to drink alcohol in traditional African societies. According to the author, indulgence in excessive consumption of alcohol and intoxication received severe punishment, and women and children were discouraged from taking alcohol. However, alcohol drinking habits are changing in many African societies as a result of societal changes, economic progress, and the expansion of the alcohol industry [6]. Te number of children who engage in alcohol consumption has increased as a result of these changes, and Ghana is no exception.
Studies in Ghana show a rise in the prevalence and involvement of children in alcohol usage [7,8]. Te 2016 Multiple Indicator Cluster Survey (MICS), for instance, indicates that 22% of males and 19% of females between the ages of 15 and 19 had, at some point, drunk alcohol [9]. Children abusing alcohol is a public health issue that has repercussions for the country's young population's welfare and development [10]. Bonnie [11] revealed that underage drinking has a number of negative efects, such as accidental death and injury, poor academic performance, and strained relationships as a consequence of alcoholism and addiction. Early alcohol consumption is also associated with an increased likelihood of adult alcohol dependence and alcohol use disorders [12,13]. In addition, drinking alcohol has been linked to an increase in youth-related violence [2].
Although drinking alcohol has detrimental efects on children, most studies conducted in Ghana have only looked at the general population [14][15][16][17]. In addition, the few studies on children and young people are not representative of the entire country [7,8,18]. For instance, a study by Hormenu et al. [7] among in-school children aged 10-15 in the central region found that 42.3% had ever consumed alcohol. Also, a study by Amoah et al. [18] among senior secondary students in Bono East region in Ghana found that 22.2% of students currently consume alcohol, while 27.9% had ever consumed alcohol. Tus, there are limited studies focusing on alcohol consumption among children using nationally representative data. Studying alcohol consumption among children using nationally representative data will help researchers and policymakers to understand better the phenomenon of alcohol consumption among children, which will help to develop efective interventions to address the phenomenon.
In light of this, the study examined the lifetime prevalence of alcohol consumption among children and the reasons underlying their alcohol use. Te study additionally investigated predictors of alcohol usage and the efect of alcohol use on children. Te efectiveness of policies in place for regulating alcohol sale and use by children in the country was also examined.

Hypothesis Development.
Previous studies have shown that the prevalence of alcohol consumption among children difers by socio-demographic characteristics such as sex and age [2,7,19,20]. For instance, previous studies have reported that alcohol consumption is more prevalent among male children than female children [8,9,21]. In addition, research has found a positive relationship between children's age and alcohol intake [9,22,23]. Based on these studies, this study tested two hypotheses as listed as follows: Hypothesis 1 (H1): males are more likely to have ever consumed alcohol than females Hypothesis 2 (H2): older children are more likely to have ever consumed alcohol than younger children

Study Design and Sampling
Procedure. Tis study used a cross-sectional convergent parallel mixed-method design to understand the phenomenon of alcohol consumption among children aged 8-17. For the purpose of this study, persons aged 8-17 are defned as children. A convergent parallel mixed-method design simultaneously gathers quantitative and qualitative data to understand a social phenomenon [24]. Te study was conducted by the Department of Children (DOC) of the Ministry of Gender, Children and Social Protection (MoGCSP) in the 10 regions of Ghana. A multistage sampling procedure was used to sample children aged 8-17. In the frst stage, 20% of districts in each of the country's 10 regions were chosen based on child protection issues such as child marriage and child labor. In 2018, Ghana had 216 districts; 43 districts (20%) were selected. In the second stage, 15 enumeration areas (EAs) were randomly selected in each of the 43 districts. In total, 645 EAs were selected. In the third stage, children aged 8-17 in each EA were selected proportionate to the district's size. It is worthy of note that in each household, only one child aged 8-17 was selected.

Quantitative Data.
For the quantitative data, a semistructured questionnaire was administered face-to-face to children aged 8-17. In total, 5,024 children aged 8-17 were interviewed.

Qualitative
Data. Ten focus group discussions (FGDs) with children between the ages of 8 and 17 were conducted as part of the qualitative data collection. Te FGDs were held in ten towns, each in a region, in convenient sites decided upon by the participants. Each FGD had a maximum of 14 participants. Also, ten FGDs were held with parents of children aged 8-17 at convenient places in ten diferent towns. In addition, ffty key informant interviews (KIIs) were conducted at convenient locations with representatives from a range of Government Ministries, Departments, and Agencies (MDAs), and Metropolitan Municipal and District Assemblies (MMDAs).

Measurement and Variables.
Te dependent variable for the study was the lifetime prevalence of alcohol consumption, which was measured with the question, "Have you ever taken alcohol?", with the response options being 1 = yes, and 2 = no.
Alcohol consumption was also measured qualitatively by asking children the types of alcohol children consumed and where they purchased alcoholic beverages. In addition, key informants were asked about measures by the Government of Ghana to protect children from substance abuse, especially regulations on alcohol sales and consumption by children.
Parents were also asked about the challenges associated with the regulations on alcohol sales and consumption.

Data Collection.
Tis study is a part of a comprehensive study by the MoGCSP on the living circumstances of children in Ghana [26]. Living and household arrangements, education and training, social amenities, children's rights, health and healthcare, sexual and reproductive health, usage of the internet and social media, child employment, and children's goals and aspirations were some of the subjects covered by the comprehensive study.
It took seven months to gather the data, starting in April 2018. A one-day workshop was held to train feld assistants on how to interview key informants and conduct FGDs with children aged 8-17 as well as administer the semi-structured questionnaire to children aged 8-17.

Statistical Analysis.
Descriptive analyses (univariate analyses), such as frequencies and percentages, were used to describe the children socio-demographic characteristics, lifetime alcohol consumption, ever been drunk, initiation into alcohol consumption, frequency of alcohol use, reasons for drinking alcohol, and perceived efects of alcohol consumption. Pearson's Chi-square and Fisher's exact tests (bivariate analyses) were employed to examine the association between the sociodemographic characteristics of respondents and the dependent variable (ever taken alcohol). Fisher's exact test is recommended when a contingency table cell has an expected frequency of less than 5 [27][28][29]. In addition, Pearson's Chi-square and Fisher's exact tests were employed to examine the association between reasons for drinking alcohol and the sex of children and the perceived efects of alcohol consumption and the sex of children, respectively.
A binary logistic regression (multivariate analysis) was performed to identify the predictors of children's lifetime alcohol usage. All the quantitative data analyses (univariate, bivariate, and multivariate analyses) were carried out using the Statistical Package for the Social Sciences (SPSS) version 26. All variables were statistically signifcant at 95% confdence interval (P < 0.05).
All interviews were audio-taped and transcribed verbatim from the local languages (such as Twi, Ewe, and Dagbani) to English. Tematic analysis was used to analyze all transcripts. All transcripts were read several times to get a general sense of children's experiences. Statements made by respondents that were pertinent to the study's objectives were given codes. Similar codes were grouped into subthemes, and similar sub-themes were grouped into themes.

Ethical Considerations. Te National Child Protection
Committee (NCPC) of the DOC of MoGCSP gave approval for the study. Te data collected for this study are part of a national monitoring exercise to evaluate the efectiveness child rights adherence in Ghana. Te data collection process adhered to the Helsinki Declaration's principles. Children's rights were observed by protecting their privacy and anonymizing the collected data. All respondents (children, parents, ofcials of parents, and ofcials of MDAs and MMDAs) who participated in the study gave informed consent before being interviewed. Table 1 shows the socio-demographic characteristics of the children sampled. Males made up more than half of the participants (51.1%). Most children (75.1%) were Christians, and a higher proportion were aged between 14 and 17 (43.7%). More children aged between 14 and 17 had signifcantly (P ≤ 0.001) ever consumed alcohol than those aged between 8 and 10 and those aged 11 and 13. More children were in primary school (42.1%). However, a higher proportion of children in SHS had signifcantly (P ≤ 0.001) ever consumed alcohol than those in other educational categories. Also, more children resided in the Brong Ahafo region (14.7%). However, more children who resided in the Volta region had signifcantly (P ≤ 0.001) ever consumed alcohol than those in other regions.

Ever Taken Alcohol and Ever Been Drunk after Consuming
Alcohol. Table 2 displays the responses from study participants about alcohol usage. According to Table 2, nearly seven percent (6.6%) of children have ever consumed alcohol. Among those who had ever taken alcoholic beverages, the majority (63.4%) got drunk after consumption. Table 3 shows the variables that predict lifetime alcohol consumption among children. Respondents not in school and those in primary schools were merged for educational Journal of Addiction 3 attainment since they did not contain enough cases for the multivariate analysis.

Initiation into Alcohol Consumption, Reasons, and Perceived Efects of Alcohol on Children.
Children were asked when they frst initiated alcohol consumption (Table 4). Table 4 shows that more than half (53.5%) of children were initiated into alcohol consumption by friends. In contrast, 17.4% were initiated by elders in their family or household.
According to the respondents (Table 4), children consume alcohol for varied reasons, including group culture (32.1%), boost confdence (21.6%), whet appetite for meals (18.6%), and taking as medicine (15.0%). Tere is a signifcant association between the initiation of alcohol consumption and the sex of children (P � 0.037). A higher proportion of male children reported group culture (51.4%), boost confdence (51.4%), and whet appetite for meals (67.7%) as their main reasons for consuming alcohol than the females. However, more females mentioned taking alcohol as medicine (58.0%) as their main reason for consuming alcohol than males (42.0%).
When asked about the efects of drinking alcohol, 39.3% believed it causes children to perform poorly in school. In contrast, 36.0% believed it causes people to become deviants or misconduct themselves. In addition, respondents reported that alcohol consumption results in accidents and fatalities (9.3%), makes a person confdent/stronger (7.2%), helps individuals forget their troubles (7.2%), and increases the likelihood of illness infection (0.9%).

Regulation of Alcohol Sale and Use among Children.
Interviews with the ofcials of the Narcotic Control Commission (NACOC) revealed that measures in place for protecting children from substance abuse include the enactment of the Narcotic Control Commission Act, 2020 (Act 1019), which is an amendment of the Narcotics Drugs (Control, Enforcement and Sanctions) Law 1990 (PNDCL 236). Te law bans narcotic drugs and also led to the establishment of the Commission, which has been successful   However, key informants explained that NACOB and other state institutions experience several challenges, including inadequate funds, afecting its capacity to fght alcohol and drug-related issues in the country. Te followings are the views expressed by key informants: Te government fnances NACOB and sometimes gets partnership funding from donors. However, we have inadequate funding, a major concern that needs to be addressed to enable us to carry out our respective mandates for efective outcomes in our operations. (KII 1).
Key informants at the Accra Psychiatric Hospital also highlighted that no therapy facility in the country is solely dedicated to providing service for children with alcohol and drug-related issues.
Most of the annual cases at the Accra Psychiatric Hospital are due to drug misuse among young people [including children]. Te fact that most therapy facilities in the country only accept adults is the main cause for concern. It is really concerning that there is now no facility in the whole country for children. (KII 3).
Regarding alcohol sale and consumption regulation, key informants narrated that the Ministry of Health has adopted a National Alcohol Policy to harmonize all laws that exist to control the production, distribution, sale, promotion, and consumption of alcohol in the country. By regulating the production, distribution, sale, promotion, and consumption of alcohol, the new policy seeks to reduce the negative consequences that alcohol abuse has on individuals and their families. A key informant had this to say: Te new Policy [National Alcohol Policy], which the Ministry of Health (MOH) and the WHO unveiled, will encourage and promote abstinence [from alcohol consumption], lessen hazardous alcohol consumption, adhere to best practices around the world, and urge the government to take the lead in guaranteeing full compliance. (KII 2).
Te FGDs with parents revealed that regulating the sale and consumption of alcohol by children in rural areas of the country is problematic. Parents in the Western and Eastern regions claimed that because the law prohibiting the sale of alcohol to minors is not strictly enforced, rural areas have a higher prevalence of underage drinking than urban areas. Te use of alcohol by young people, especially children, has also been linked to disrespect, criminal activity, and other aberrant behaviors, according to parents. One parent explained: Many of the children around here are alcoholics. Tey drink and misbehave in their homes and on the streets, and when adults dare to object, they will be beaten up or insulted. Due to their alcoholism, many parents no longer have complete control over their children in the community. (FGD 7).
FGDs with children confrmed that children consumed local alcoholic beverages, including palm wine and "Akpeteshie" (a popular locally produced alcoholic beverage in Ghana). Children often purchase alcoholic beverages from neighborhood bars, especially in rural areas, and bars in rural areas have no limitations on selling alcoholic beverages to children compared to urban areas. One key informant expressed: All the drinking bars allow children to enter freely and purchase alcohol. Who they sell to is irrelevant to the bar owners. Teir sole focus is on increasing sales. Tey refuse to heed the summons, despite the complaints of their parents and elders. (FGD 20).

Discussion
Tis study aimed to examine children lifetime prevalence of alcohol consumption and their reasons for alcohol consumption. Te study also investigated predictors of children lifetime alcohol use and the efects of alcohol consumption on children. It furthermore examined the efectiveness of policies in place for regulating alcohol sale and use among children in Ghana.
Te study found that children lifetime prevalence of alcohol consumption was 6.6%. Children lifetime prevalence of alcohol consumption in this study is lower than prevalence found previous studies from Ghana [7][8][9]18], Nigeria [19,21], and Iran [30]. For instance, Roshanfekr et al.'s [30] study among street children in Iran found that 16.6% had ever consumed alcohol. In Ghana, a study by Hormenu et al. [7] among in-school adolescents found that 42.3% of adolescents had ever consumed alcohol. Te discrepancies in the prevalence of alcohol consumption could be attributed to varied factors, including diferences in the sample population, measurement of alcohol consumption, and the studies not covering the whole country. For instance, previous studies on alcohol consumption among children in Ghana focused on selected regions in Ghana, namely, Central [7], Eastern [8], and Bono East [18] regions, than the entire country. Also, Alex-Hart et al.'s [19] study was among secondary school students, while Roshanfekr et al.'s [30] study was among street children. In terms of measurement of alcohol consumption, Hormenu et al.'s [7] study in Ghana measured alcohol consumption among in-school adolescents using how old respondents were when they had their frst alcoholic drink.
Te study also found that males are more likely to have ever consumed alcohol than females. Tis fnding supports the frst hypothesis that males are more likely to have ever consumed alcohol than females. Te fnding is consistent with prior studies [9,19,21], showing that alcohol consumption is more prevalent among males than females. Cultural expectations of masculinity may explain the high prevalence of alcohol consumption among males [5,31,32]. Culturally, alcohol consumption is acceptable for men but disapproved of for women [5]. However, this fnding contrasts with previous studies in Ghana [8] and the United States [20], which found a high prevalence of alcohol consumption among females than males.
Regarding the age of children, our study found that there is a positive association between alcohol consumption and children's age. Tus, children aged 14-17 years are more susceptible to alcohol consumption than children aged 8-10 years. Tis fnding confrms the second hypothesis that older children are more likely to have ever consumed alcohol than younger children. Tis fnding corroborates earlier studies which found that alcohol consumption increases with age [2,9,22]. For example, a study by Aboagye et al. [23] among Ghana's tertiary students found a positive relationship between alcohol consumption and the age of students. Similarly, a study by Hormenu et al. [7] among inschool adolescents found that older adolescents (14-15 years) consumed more alcohol than younger adolescents (12-13 years). A plausible explanation is that as children grow, they are increasingly exposed to advertisements on alcoholic beverages, which may entice them to consume them.
Te results also indicated that 1.4% of children aged between 8 and 10 had ever consumed alcohol. Zucker et al.'s [33] study found that early alcohol usage (before the age of 12) is linked with an increased risk of developing alcoholrelated challenges during adulthood. Dunn and Goldman's study [34] highlighted that children's negative perceptions of alcohol and its efects change as they age. Older children, by extrapolation, have a higher alcohol consumption urge than younger children. Tis points to the importance of early interventions to discourage the early initiation of alcohol to forestall the development of alcohol-related challenges in later life.
Regarding the region of children's residence, the fndings indicate that children from the Eastern and Northern regions are signifcantly less likely to have ever consumed alcohol than children from the Greater Accra region. A plausible explanation is that the Greater Accra region, which has Accra, the capital of Ghana, is often the epicentre of programs and advertisements on alcoholic beverages. Te exposure of children in Greater Accra to programs and advertisements on alcoholic beverages may explain why they are more likely to have ever consumed alcohol. Studies have linked increased advertisements on alcoholic beverages with increased consumption of alcohol [35][36][37].
Our results also highlighted that more than half of children (53.5%) were infuenced by friends to initiate alcohol consumption. Tis result corroborates other studies which found peer infuence as a major predictor of alcohol consumption among children [38][39][40]. Proximately 17% of children were infuenced by their older family members to initiate alcohol consumption, which supports the fndings of earlier studies [5,31]. Our result also showed that 17% of children consumed their frst alcohol at social gatherings, corroborating previous research fndings [41]. Twelve percent of children had their frst alcoholic beverages at drinking bars, and this phenomenon is more prevalent in rural areas [42,43]. Tis result is not unexpected given the wide variety of drinking bars/pubs in Ghana [44], and it is common for adults and parents to send children to purchase alcoholic beverages at these drinking places [45].
In addition, this study found that alcohol consumption was part of children's group culture, corroborating previous studies which found peer group infuence as a signifcant determinant of children attitudes and actions [38]. When some members of a group consume alcohol, it is possible other members may be infuenced to initiate alcohol consumption due to group culture. Some children were motivated to consume alcoholic beverages to boost their confdence (21.6%), whet their appetite for meals (18.6%), and as a medication for the treatment of their ailments (15.0%). Tis fnding is unsurprising since advertisements on alcoholic beverages highlight these attributes, infuencing children to consume alcohol [46]. Studies have also documented the use of alcohol in preparing herbal medications to treat ailments [47,48]. Furthermore, 7.5% of children reported that drinking alcohol was a ritual in their groups or homes, supporting other studies [41]. Also, 5.1% of children reported consuming alcohol to forget their worries. Tis fnding supports previous studies, which found that adults sometimes consume alcohol to forget about problems/issues [49][50][51]. Tis fnding highlights the need for health practitioners and policymakers to educate children on active coping strategies for their daily challenges.
Respondents mentioned varied efects of alcohol consumption, including negative impacts on academic achievement, involvement in delinquent behavior, occurrences of accidents and fatalities, enhanced self-assurance, forgetting challenges, and heightened susceptibility to contracting diseases. Despite children being knowledgeable about the negative efects of alcohol consumption, there is a need to strengthen public education on alcohol consumption to reduce the prevalence of children's alcohol consumption.
Our results highlighted the availability of regulations, policies, and state agencies to regulate children's alcohol consumption and its efects. Despite these measures (legislations, policies, and state agencies), the sale of alcoholic beverages to children and children alcohol consumption is a common phenomenon. Also, there is a weak enforcement of regulations on selling alcoholic beverages to children in rural areas, making those children more susceptible to consuming alcohol. Tis fnding is similar to a study by Senya and Floyd [52] in Ghana, which found that most sellers of alcoholic beverages (85%) were willing to sell alcohol to children to increase their sales, although they were aware it was unlawful.
Furthermore, alcohol intoxication made children in rural areas to exhibit negative behavioral outcomes, including disrespect, violence, rebellion, and disregard for the law. Tis result supports other studies which reported alcohol-related problems, including rebellion [53], violence [54], unruliness, and disrespect for authority [55,56]. Inferring from the results, children who reside in rural areas are a vulnerable population to indulge in underage alcohol consumption. Hence, policymakers and researchers need to focus on this population to better understand their needs to enhance their health and general wellbeing due to the adverse efects of underage alcohol consumption on children. In addition, policymakers should ensure the enforcement of regulations on alcohol sales and use among children, especially in rural areas. In addition, organizations mandated to deal with the menace of underage alcohol consumption in the country should strengthen their eforts in public education regarding the adverse consequences of alcohol consumption on children and the general population.

Limitations
Tis study has some limitations. Children were inquired regarding their history of alcohol consumption. Due to the perception of underage alcohol consumption as deviant and illegal for individuals below the age of 18, there is a likelihood that children may provide inaccurate or incomplete accounts of their involvement in such activities. Also, the study was cross-sectional. Hence, causality cannot be established. Tird, studies have identifed vital variables that predict alcohol consumption, including peer and parental use of alcohol, household wealth quintile, and academic adjustment problems [16][17][18]23]. However, these variables were not included in the binary logistic regression since they were unavailable in the dataset. Despite these limitations, the fndings of this nationally represented study deepen health practitioners' and policymakers' understanding of children's alcohol consumption in Ghana, which will aid in designing appropriate interventions to curb the phenomenon.

Conclusions
Our results showed that children lifetime alcohol consumption was less than one-tenth (6.6%). Lifetime alcohol consumption was prevalent among older children (14-17 years), children with senior high school education, and males. Again, friends were a major determinant of alcohol consumption among children. Most children got drunk after consuming alcohol, and boosting confdence was the main facilitator of alcohol consumption among children. Te fndings of the study demonstrated that the government's eforts to stop the sale and consumption of alcohol by children have been inefective.
Furthermore, the sex of children, age of children, and region of residence were signifcant predictors of alcohol consumption among children aged between 8 and 17. Policymakers should target these characteristics when developing interventions to reduce alcohol consumption among children.

Data Availability
Te raw data for the fndings of this study are freely available from the corresponding author upon request.

Disclosure
Tis manuscript was earlier submitted as a preprint to the Research Square [57].

Conflicts of Interest
Te authors declare that there are no conficts of interest.

Authors' Contributions
Tis study was conceived and designed by SK-G and FK-A. Te data processing and analysis were conducted by SK-G and FK-A. Te manuscript was prepared by SK-G, NW, and FK-A. All authors contributed to the editing and fnal approval of the manuscript for submission.