Keywords
Alcohol, Children, Health Problems, Peru
Alcohol, Children, Health Problems, Peru
This version has been revised according to the suggestions sent by our reviewers. These suggestions are focused on:
- Improvement in definitions and conceptualization of the origin of artisanal drinks of Peruvian origin (Chicha de Jora and Clarito).
- Improvement of the writing and correction of typing errors.
- And finally, improving the writing of percentages in the Discussion and Results sections, for a better and clearer understanding.
On behalf of the authors, we thank you for your interest and we present the improved version.
See the authors' detailed response to the review by Paul Anthony Camacho López
See the authors' detailed response to the review by Dirk W. Lachenmeier
Alcoholic beverages, which are traditionally derived from the fermentation of sugars and yeast1, currently have a large socio-economic impact. The World Health Organization states that 3.3 million deaths are caused every year worldwide by the harmful use of alcohol2. It is well known that these types of drinks cause a series of physiological problems (renal, digestive, hepatic, etc.)3,4, as well as behavioral problems, which include maladaptation to the family and social environment, and, in extreme situations, could lead to suicide5.
According to worldwide data, alcohol use has 5.1% comorbidity (high blood pressure, cirrhosis, renal disease, etc.) in the age group between 20–39 years6. However, some countries, such as Colombia and Argentina, have reported onset at an earlier age7. In Peru, there is almost no information on this subject (information that is provided is mostly provided by local institutions); however reports show that the median age when alcohol consumption begins is 13 years, while in locations where children have greater access to alcoholic beverages, consumption starts at 10 years8.
Chicha de Jora (Ch) and Clarito (Cl) are drinks derived from the fermentation of maize that have been consumed since Pre-Hispanic times throughout the northern coast of Peru. The Incas, among the types of corn that they cultivated considered the germinated corn (Jora) as a sacred drink; giving two derivatives of alcoholic content (Chicha de Jora and Clarito). This tradition has been passed from generation to generation until today. Currently, the elaboration of this millenary drink in Peru (especially in the North Coast) is done by hand, not having a formal regulation by the industry9; thus reaching about 28.7% of unregistered alcohol registered by the World Health Organization (WHO)10, since consumers despite having between 10 to 12 degrees of alcohol, they consider this as a traditional drink10.
Consumption is high due to their low production cost, ease of access, and tradition11. These factors can create a problem if such drinks are consumed by children and teenagers. The objective of this study was to characterize the consumption of these traditional alcoholic beverages in children of a rural village in Northern Peru.
A cross-analytical cross-sectional study was carried out between February and May 2017, in which the mothers and/or guardians of the Northern Peruvian settlement of "La Piedra", where 308 children under the age of 15 reside, were surveyed. Household visits were completed for the purposes of the study. Thanks to the information provided by the governor, the surveys were carried out in each of the homes of the mothers and/or guardians using census sampling. A sample size was calculated for a descriptive study, for the local population of children, with a statistical power of 99%, a 95% confidence level and a maximum prevalence of 50%. A minimum sample of 300 children was obtained; this was captured non-randomly.
All mothers residing in the populated center (small town) during the interview were included. Mothers who did not wish to participate in the study, as well as those mothers who responded inadequately to our survey were excluded. After reading through the informed consent and agreeing to participate the mothers were enrolled in the study. Those who did not respond adequately to the survey (unanswered questions and/or incomplete answers) were excluded. Rate of rejection = 2.5%, thus achieving a total of 300 surveys applied, obtained from the interview of 103 mothers or guardians (in some cases the mothers or guardians had more than one child).
For the present study, a survey was carried out, which was previously validated by a pilot study in a sample of 50 individuals, where a Cronbach's alpha of 0.781 was obtained. The previous pilot study was not published, the results were only for the evaluation of the survey. The survey had minor modifications after the pilot study. These were used to specify the details of consumption, access and even the consequences of the consumption of alcoholic beverages. The final survey had two main sections (Supplementary File 1):
Socio-demographic data: Basic data was provided, such as the child’s age, weight, height and school grade, and in addition the number of household members and household income.
Characteristics of drinking habits in liquids/beverages: These characteristics were evaluated through closed questions, in which inquiries were made about the daily consumption of different drinks, primarily the consumption of beverages containing alcohol (Ch and Cl). The following information was obtained: the frequency of consumption (1 day a week; 2 days a week; Every day; No consumption), the accessibility of beverages (Very low cost - less than S/.1 Sun/Bottle; Low cost - less than S/.5 Soles/Bottle), whether or not consumed by the person who responded to the survey and by the whole family, and if the consumption of the beverages was perceived as harmful or nutritional for the child's health. Finally, other exploratory variables were captured, such as the consumption of other types of beverages (aerated beverages, pure water, milk, lemonade, Chicha Morada, etc. - all of them without alcohol content); and a section where the child's socio-academic problems were assessed was included. These exploratory variables are not discussed in the present study.
All surveys were anonymous and were conducted by a researcher belonging to the study. The approximate duration of the survey was 20 minutes. At all times the assigned researcher was properly trained to be able to solve doubts about any of the questions.
For the data analysis, a double digitizing system (data processed by two researchers separately, and then checked for errors manually) was performed, for a better control of the data collected. Surveys were entered in the Microsoft Excel program (version 2015), then proceeded to make a first filter for checking the data. Following this, the data were processed in Stata 11.1 (StataCorp LP, College Station, TX, USA).
For descriptive statistics, we worked with frequencies/percentages for categorical variables, and medians and interquartile ranges for the quantitative variables. The chi-square statistical test was applied for the association of the consumption of the drinks versus the perception that the consumption of the drinks could be bad for children. P<0.05 was considered statistically significant.
Permission and support was provided by local authorities (governor, health center doctor and school director). Since children were the target of this study, all precautions were taken to ensure anonymity and respect for ethical precepts. The study was approved by the Ethics Committee of the San Bartolomé National Hospital, endorsed by the National Health Institute (NIH; approved March 5, 2016; Office No. 422). This committee was chosen since there is no committee that monitors the approval of the NIH where the study was conducted. This committee also approved the pilot study. The ethical standards on human experimentation of the Declaration of Helsinki of 1975 were taken into account. The results will be given to the sanitary authorities of the region, so that they can learn about this reality and put forward strategies of help. The study was carried out under the permission of the mothers/guardians, who gave written informed consent.
Data were collected about 300 children, 51.3% (154) were girls, and the median age was 9 years (interquartile range: 5–12 years). 15.8% (41) studied at an initial level, 53.5% (139) studied in a primary school and 30.7% (80) studied in secondary school. 61.0% (183) and 30.7% (92) consumed Ch and Cl, respectively (Table 1).
Beverage | Child consumption, n (%) | Consumption frequency, per week | Consumption initiated, years |
---|---|---|---|
Chicha de Jora | 183 (61.0) | 3 (1-7) | 3 (2-5) |
Clarito | 92 (30.7) | 3 (1-7) | 4 (2-5) |
Most of the mothers reported that they consumed Ch (84.7%) and Cl (62.7%) when they were children, and the majority also consume the drinks now (Ch: 74.0% and Cl: 47.7%). Regarding accessibility of the beverages, the majority of mothers said that these drinks were cheap (Ch: 69.0% and Cl: 60.7%), and the vast majority of families sometimes consumed or always consumed such beverages (Ch: 81.3% and Cl: 65.7%) (Table 2).
35% of mothers perceived that Ch is nutritious and helps growth, while 33% and 35% of mothers perceived that Cl is nutritious and helps growth, respectively (Figure 1). 25% of mothers perceived that there was no risk for their child to consume the beverages. However, >60% said that there could be a risk due to the alcohol contained in the drinks (Table 3).
Figure 2 shows that although women perceive consumption of beverages as bad for their children, 46% and 34% still gave their children Ch and Cl, respectively.
The consumption of alcohol in children is still a very important problem, as evidenced in this study, where out of 300 children surveyed, 183 and 92 children consumed Chicha de Jora (Ch) and Clarito (Cl), respectively, every week. These results of consumption are greater than in different studies from different countries. For example, in Brazil, only 12.8% of children consumed any type of alcoholic beverage before age 1012; in the Province of Buenos Aires, 55.4% of adolescents between the ages of 11 and 14 consume alcohol13; while a study in Colombia, with children at the mean age of 14.4 years, concluded that the pattern of alcohol abuse measured by the CAGE scale was 14.6%14.
The consumption of these traditional beverages also occurred during the mothers' childhood, with a majority stating that they had consumed both drinks. Many of the mothers expressed that they still consume them. A report of a population study in Chile, of 408 alcoholic respondents, reported that 27.2% lived with children in the house and in 46.3% of cases the drinker was either the father or the mother15. Another report in Angola showed that 56% of mothers of 319 children had regular alcohol habits. Our study showed that this percentage was higher at 84.7% of mothers who consume Ch and 62.7% who consume Cl16. Also in Brazil, Argentina, Colombia, Chile, and Mexico, it was reported that occasional consumption of alcohol is associated with family context, influence of friends, antisocial behavior, and skills and experiences already acquired in childhood, which could be circumstances that encourage the consumption of alcohol in children12–14,17,18.
The consumption of alcohol in younger populations has risen in recent years in Peru, which has the potential to cause harm and create addictive behavior18. In our population, the acquisition of Ch (69.0%) and Cl (60.7%) was considered economical-average cost: 1 to 5 Soles / Bottle (0.80 Euros)- because of their low cost of production; therefore making them more accessible and frequently consumed. One in every three mothers perceived that the Ch and Cl are nutritious and help the growth of their children, and this is a perception that could lead them to giving these drinks to their children. A study from Spain reported that fathers and mothers do not consider their children's alcohol consumption to be a problem19, thus increasing their early intake without restriction.
In the present study, most mothers knew about the risk of alcohol consumption by children. However, it was observed that the consumption in most of their children remained high. Studies carried out in Spain and Cuba indicate that the family can be a protection, but also a risk factor. In both cases, the maternal figure tends to have a positive influence on the child, which differs from what was found in the present study19,20. We can infer that this is mainly due to a socio-cultural characteristic where the community (and especially the mothers) view the consumption of these traditional alcoholic beverages as normal.
The study had the limitation of selection bias, since it was completed in a sample that does not represent the total population of Peru. Likewise, since this is a preliminary study, its non-quantitative nature also counts as a limitation. However, this study used census-type sampling in a population that had not been previously reported; therefore, these results can be taken as preliminary. In particular, these findings can be used to alert the responsible authorities, so that detection and support measures can be implemented, so that families in this village and similar locations with similar consumption conditions can receive the necessary support.
According to the present study, it is concluded that children consume traditional alcoholic beverages and that their mothers provide access. Although mothers perceive the risk that these drinks have, they still give them to their children. Finally, there could be a danger to health, however, further studies would be necessary in a quantitative manner, which would more accurately assess this risk.
Dataset 1: Raw data from the responses of mothers/guardians concerning their children’s consumption of traditional alcoholic beverages (n=300 children). doi, 10.5256/f1000research.12039.d17015821
Supplementary File 1: Survey for mothers/guardians relating to the consumption of traditional alcoholic beverages in their children. This survey is provided in Spanish and English.
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Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
References
1. World Health Organization: Global status report on alcohol and health 2018. 2018.Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Qualitative assessment of unrecorded alcohol consumption and harm in clinical populations, alcohol policy research with a special focus on unrecorded alcohol
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Risk assessment of unrecorded alcohol
Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
References
1. Rehm J, Kailasapillai S, Larsen E, Rehm MX, et al.: A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol.Addiction. 2014; 109 (6): 880-93 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Risk assessment of unrecorded alcohol
Alongside their report, reviewers assign a status to the article:
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Version 1 28 Jul 17 |
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