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ORIGINAL ARTICLE

Does academic streams influence alcohol use in colleges?

Priya G. Menon, Abel Thamby1, K. P. Jayaprakashan2, Anjana Rani, B. Sivasankaran Nair, K. Thennarasu3,
T. S. Jaisoorya1
Department of Psychiatry, Government Medical College, Ernakulam, 2Department of Psychiatry, Government Medical
College, Thiruvananthapuram, Kerala, Departments of 1Psychiatry and 3Biostatistics, NIMHANS, Bengaluru, Karnataka, India

ABSTRACT

Background: Alcohol use among college students is a major public health priority owing to its high prevalence and
numerous negative outcomes. Most interventions targeting alcohol use among college students consider them as a
homogenous entity. There is preliminary evidence from high‑income countries that patterns of alcohol use differ across
academic streams. This remains unstudied in India.
Aims: To compare the prevalence and correlates of alcohol use among students enrolled in various collegiate educational
streams (medical, nursing, engineering, arts and science, and others [law/fisheries]) in the state of Kerala, India.
Settings and Design: This is a cross‑sectional survey conducted among college students.
Materials and Methods: 5784 students completed a self‑administered questionnaire assessing alcohol use and its
correlates in the psycho‑social domains.
Statiscal Analysis: Lifetime prevalence and severity of alcohol use was determined across examined academic streams.
A multivariable logistic regression analysis was done separately for each course, to identify factors influencing alcohol
use.
Results: The lifetime prevalence of alcohol use varied between 10.6% among nursing students to 41.7% among students
pursuing “other” stream (law/fisheries). Students pursuing medicine and nursing had a relatively lower proportion of
hazardous users. Consistently across all academic streams, being male and using tobacco increased the risk, while those
from the Muslim community had a lower risk of alcohol use. Other examined psychosocial correlates showed varying
relationship across courses.
Conclusion: The prevalence and psychosocial correlates of alcohol use vary among students pursuing various academic
streams. This finding has public health importance as the incorporation of course level characteristics in intervention
programs will improve effectiveness.

Key words: Alcohol use, colleges, courses, India, Kerala

INTRODUCTION

Alcohol use among college students is a key public health

Address for correspondence: Dr. T. S. Jaisoorya, priority, given its adverse health and academic outcomes.
NIMHANS, Bengaluru ‑ 560 029, Karnataka, India.
E‑mail: tsjaisoorya@gmail.com Among young people, it accounts for more than 10%
Submitted: 13‑Aug‑2020, Accepted: 22‑Oct‑2020, This is an open access journal, and articles are distributed under the terms of
Published: 15-Feb-2021 the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
Access this article online as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Quick Response Code
Website: For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
www.indianjpsychiatry.org

How to cite this article: Menon PG, Thamby A,

DOI:
Jayaprakashan KP, Rani A, Nair BS, Thennarasu K, et al. Does
academic streams influence alcohol use in colleges? Indian J
10.4103/psychiatry.IndianJPsychiatry_976_20
Psychiatry 2021;63:28-34.

28 © 2021 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

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Menon, et al.: Academic streams and alcohol use in colleges
of the overall burden of injury and disease.[1] Students
with problematic alcohol use have a higher risk for poor
academic achievement, risky sexual behaviour, accidents,
mental health issues, suicide, and later addiction.[2‑4]
Studies from high‑income countries (HIC) have reported
that most college students drink (90%), with a significant
proportion reporting “binge drinking” (25%–50%).[4‑6] Most
studies from Asia have reported lower rates of heavy
drinking of around 10%.[5] Studies from India are a few and
have reported widely varying prevalence of 20%–50%.[7‑9]
These studies have examined college students as a
homogenous group. However, the environment in
colleges can no longer be considered a single culture.[10]
There is anecdotal evidence suggesting that alcohol use
patterns vary according to the choice of an academic
field. Different workloads (having no classes on Friday) or
specific gender characteristic (e.g., a higher proportion of
females in nursing) is reported to influence alcohol use
in campuses.[5,11] Also, several factors such as duration of
courses, institution’s predominant ethnic characteristics,
having active athletic/sports program, and membership in
clubs/fraternities have been inconsistently linked to alcohol
use.[5,12,13] These findings from Western campuses have
limited generalizability to India. There is a lower prevalence
of alcohol use in India (and other Asian countries) compared
to European countries or the USA.[5,8] The sororities,
fraternities, or special athletic clubs of the Western
university systems are nonexistent in India. In contrast
to the West, only a few large universities in India offer a
wide variety of courses. Most Indian colleges offer courses
restricted to a specialized stream (e.g., arts and science,
engineering, and nursing).[14]
Despite these differences, there is preliminary evidence
that variation in alcohol use across different courses may
be the case in India also, with a small study of 297 male
students in 4 different educational streams reporting
variation of prevalence across courses.[15] Understanding the
unique patterns of alcohol use among students in various
academic streams has significant public mental health
importance. For most young people, the period of transition
to adulthood represents greater vulnerability to yield to
environmental norms. Exposure to campus with a culture
of drinking can thus lead to both initiation and increased
alcohol use.[12] It would also be vital to understand whether
the commonly‑reported correlates of alcohol use in the
sociodemographic and psychosocial domains such as age,
gender, religion, socioeconomic status, place of residence,
tobacco use, family structure, suicidal risk, and emotional
distress among students using alcohol pursuing different
academic streams.[5,8,16] Incorporating the protective
and risk factors of the unique academic environment of
various streams of higher education may ensure improved
effectiveness of interventions. The reach and impact of
Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021
any college intervention is more significant as students in
college represent the cream of the country’s future.[14]
Hence, this study examined the differences in prevalence
and correlates of alcohol use among students in college
pursuing the five common streams of higher education:
that is, medical, engineering, arts or science, nursing, and
others (law or fisheries) in Kerala, India. This study is a part
of a bigger research project which examined substance use
and other psychological issues among students pursuing a
college education.
MATERIALS AND METHODS
This survey was done in 58 of the 123 colleges in Ernakulam
district, Kerala. The colleges were first categorized to five
academic streams (medical, engineering, arts and science,
arts or science, and others [law or fisheries]). The colleges
were then selected by cluster random sampling with
academic streams forming the clustering unit. In each of the
selected colleges, the survey was conducted in two classes,
either even or odd years (i.e., second and fourth year, or
first and third year). The classes were allocated by the head
of the institution.
All students were informed about the objectives of this
survey and requested to participate. They were assured that
their responses would be anonymized with nonparticipation
having no impact on their academic grades. Students who
gave informed consent were administered the paper and
pencil questionnaire under exam conditions. Students
could opt for either the English or Malayalam version of the
questionnaire. The survey instrument designed in English
was translated to Malayalam and back‑translated to ensure
it is conceptually congruent. The students were supervised
by the faculty of the Psychiatry Department, Government
Medical College, Ernakulam.
Information on sociodemographics was collected using a
checklist (age/sex/religion/socioeconomic status/residence).
In addition, the following structured instruments were
used.
Alcohol
Alcohol, Smoking, and Substance Involvement Screening
Test (ASSIST) was employed to evaluate alcohol use.[17] In
addition to lifetime alcohol use, among users, the ASSIST
assesses patterns of use, frequency of urges, problems
experienced, concerns raised by friends/family regarding
alcohol, and attempts to reduce or stop use. The total
score as per ASSIST is the “alcohol involvement score.”
An alcohol involvement score of 0–10 indicates low‑risk
user or abstainer (those using alcohol occasionally or not
currently using, with a less likelihood of experiencing
harm, currently or the future, with the same pattern of
use); score of 11–26 indicates hazardous use (pattern
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Menon, et al.: Academic streams and alcohol use in colleges

of consumption that increases the likelihood of adverse
effects, physical, psychological or social); and score
27+ indicates dependence (has difficulty in quitting despite
serious problems in various domains). ASSIST has been
validated as a screening tool in developing countries and
has good test–retest reliability.[17] The study also evaluated
the consumption of tobacco but for this paper, lifetime use
of tobacco has been considered.
Psychological distress
Psychological distress in the past 2 weeks was assessed
using Kessler’s Psychological Distress Scale (K10) scale.[18]
The scale has ten questions about anxiety and depressive
symptoms scored on a 4‑point Likert scale. Higher scores
suggest greater distress. K10 is validated for the screening
of psychological distress in India.[19]
Suicidality
Lifetime suicidality was evaluated by the following screening
questions: “Have you ever thought of committing suicide in
your life?” and “Have you made a suicidal attempt in your
lifetime?”
Ethics
This study received clearance from the Institute Review
Board of Government Medical College, Ernakulam.
Statistical analysis
Statistical analyses were conducted by using  R software.[20]
Lifetime prevalence and alcohol use severity was calculated
among students in the examined academic streams.
The association of alcohol users and nonusers with
sociodemographic variables in different courses was
examined using the Chi‑square test for categorical and
two‑way ANOVA with Bonferroni correction for continuous
variables. Multivariable logistic regression analysis (full
model) was used to examine the relationship of alcohol
use with psychosocial variables for each of the courses
separately. Students in nursing, however, had low baseline
prevalence of tobacco use (n – 3 [0.5%]) and hence tobacco
was excluded in the full model examining nursing. The
findings are reported as odds ratio and 95% confidence
intervals. The statistical significance was set at P < 0.05.
RESULTS
A total of 5784 college students in five academic streams
took part in the cross‑sectional survey. The break‑up of
students surveyed and the number of institutions in each
stream are described in Table 1.
Of the total of 5784 students surveyed, 342 questionnaires
were discarded as it had substantial missing responses
providing 5442 (94.1%) questionnaires for analysis. The
mean age of the students was 19.8 ± 1.4 years with a
higher proportion of females (n – 3545 [65.1%]). This reflects
the enrollment pattern in colleges of Kerala.[21]
The lifetime prevalence of alcohol use varied between 10.6%
among nursing students to 41.7% among students pursuing
“other” stream (law/fisheries). Male students reported
prevalence between 15% in nursing to 55.4% among “others.”
Among female students, the lowest prevalence was among
students pursuing arts and science (9.3%) and highest
among students in “other” courses (32.5%). Male students
had a significantly higher prevalence of alcohol use when
compared to females in all examined streams (P < 0.001).
Male students enrolled in nursing was too low (n – 20 [3.3%])
hence gender association could not be examined [Table 2].
The severity of alcohol use calculated by mean ASSIST
Scores after Bonferroni correction showed severity was
comparable among those pursuing nursing and medical.
The severity of alcohol use among those pursuing arts and
science, engineering, and other streams was significantly
higher compared to those in nursing (P < 0.05). Hazardous
use was lowest among alcohol users in the nursing
stream (4.7%) followed by medical (12.6%) and arts and

Table 1: Colleges and sample surveyed for each specialised course

Courses offered Number of institutions surveyed Sample size as a proportion of total N (%)
Sub‑stream Major stream Sub‑stream Major stream
Medical 8 986 (17)
Allopathy 2 413 (7.1)
Ayurveda 2 208 (3.6)
Homoeopathy 1 149 (2.6)
Dental 3 216 (3.7)
Nursing 8 620 (10.7)
Arts (including Undergraduate and Postgraduates) 25 2436 (42.1)
Engineering (including degree and diploma students) 14 1310 (22.6)
Degree 11 1018 (17.6)
Diploma 3 292 (5)
Others 3 432 (7.6)
Law 2 346 (6)
Fisheries 1 86 (1.6)
Total 58 5784

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Menon, et al.: Academic streams and alcohol use in colleges

science (17.6%). Students in engineering (20.2%) and academic failures, psychological distress, and tobacco
“others” (26.4%) had the highest proportion of hazardous consumption; those pursuing nursing reported suicidal
users. There was a significant association between student thoughts; those in engineering reported academic failures,
course and ASSIST categories (P < 0.001) [Table 3]. As the tobacco use, and suicidal thoughts; those in arts and
mean age of the study participants was low, the proportion science reported tobacco use, psychological distress, and
of dependent users was low across all academic streams. suicidal thoughts; and in “other” streams tobacco use and
psychological distress [Table 5].
Alcohol users among students pursuing engineering and
arts and science streams were significantly older. Across DISCUSSION
all streams, students from the Muslim community were
significantly less likely to use alcohol. Students from urban This study is among the largest from India that has compared
areas pursuing medical and “other” streams and those the prevalence of alcohol use amongst students in various
from rural background pursuing arts and science were academic streams of higher education. Our finding that the
significantly more likely to consume alcohol [Table 4]. prevalence of alcohol use varies across academic streams
even when students are from geographically proximal
In the full model of logistic regression examining the institutions with comparable sociocultural background
psychosocial correlates of alcohol use, college students suggests that course characteristics influence alcohol use.
using alcohol in the medical stream had higher odds of This finding has been reported prior though no clear patterns
have emerged.[22‑25] These studies are almost exclusively
Table 2: Prevalence and severity of alcohol use among from Europe and North America which have a different
students across various courses academic and drinking culture.[22‑25] Other methodological
Streams Lifetime prevalence issues such as differing instruments and varying definitions
Male, n (%) Female, n (%) Total, n (%) also complicate the direct comparability of our results.
Medical (n=960) 50 (27.2) 107 (13.8) 157 (16.4) A previous study from India suggested a similar trend but
Nursing (n=603)* 3 (15) 61 (10.5) 64 (10.6) was inconclusive owing to its small size.[15] Our study did
Engineering (n=1253) 307 (40.7) 62 (12.4) 369 (29.4) not, however, examine the possible reasons for the between
Arts and science (n=2209) 275 (35.7) 134 (9.3) 409 (18.5)
Others (n=417) 93 (55.4) 81 (32.5) 174 (41.7)
course variation in prevalence. Though understudied, many
Figures in bold ‑ Male versus female indicate P<0.001. *Gender differences not
factors including academic load, knowledge and attitudes
examined as males enrolled in nursing was low (n=20; 3.3%) toward drinking, demographic and ethnic profile of

Table 3: Severity among life time users (as per alcohol, smoking and substance involvement screening test scores)
Streams Mean ASSIST Low risk users, n (%)† Hazardous users, n (%)† Dependent users, n (%)†
score (SD)
Medical 3.73 (5.52) 136 (87.1) 20 (12.3) 1 (0.6)
Nursing 1.39 (3.83) 61 (95.3) 3 (4.7) 0 (0.0)
Engineering 5.69 (6.24) 293 (79.3) 74 (20.2) 2 (0.5)
Arts and science 5.25 (6.53) 332 (81.1) 72 (17.6) 5 (1.2)
Others 6.79 (6.70) 125 (71.8) 46 (26.4) 3 (1.7)
†
As a proportion of total users. SD – Standard deviation; ASSIST – Alcohol, Smoking and Substance Involvement Screening Test

Table 4: Socio‑demographic correlates of alcohol users in various courses

Medical, n (%) Nursing, n (%) Engineering, n (%) Arts and science, n (%) Others, n (%) Total sample, n (%)
Age years (mean±SD) 20.6±1.5 19.6±1.3 19.4±1.3 20.0±2.1 19.3±1.6 19.8±1.4
Family structure
Living with parents 137 (87.3) 54 (84.4) 336 (90.1) 363 (88.4) 151 (86.8) 4815 (88.1)
Single parent family 9 (5.7) 2 (3.1) 15 (4.0) 22 (4.2) 12 (6.9) 297 (5.7)
Living with relatives/others 11 (7.0) 8 (12.5) 18 (5.1) 24 (7.4) 11 (6.3) 330 (6.2)
Religion
Hinduism 73 (46.5) 9 (14.1) 200 (53.8) 215 (52.5) 122 (71.3) 2502 (46.9)
Christianity 80 (51.0) 55 (85.9) 155 (42.2) 177 (43.4) 40 (22.8) 1879 (33.2)
Islam 4 (2.5) 0 (0) 14 (4.0) 17 (4.2) 12 (6.0) 1061 (19.9)
Socioeconomic status
APL (above poverty line)* 150 (95.5) 52 (81.3) 326 (87.7) 321 (78.6) 164 (94.8) 4510 (83.0)
BPL (below poverty line)* 7 (4.5) 12 (18.7) 43 (12.3) 88 (21.4) 10 (5.2) 932 (17.0)
Residence
Urban 85 (54.1) 19 (29.7) 164 (44.5) 186 (45.3) 144 (82.8) 2307 (42.3)
Rural 72 (45.9) 45 (70.3) 205 (55.5) 223 (54.7) 30 (17.2) 3135 (57.7)
Figures in bold indicate P<0.05 for comparison of alcohol users versus nonusers in examined variable/course. *Socioeconomic indicators of Government of India

Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021 31

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Table 5: Psychosocial correlates of alcohol use
Total sample, n (%) Medical Nursing Engineering Arts and science Others
n (%) OR (95% CI) n (%) OR (95% CI) n (%) OR (95% CI) n (%) OR (95% CI) n (%) OR (95% CI)
Part‑time job (n=441; 8)
Nonuser 15 (1.8) 1.0 2 (0.4) - 66 (7.4) 1.0 191 (10.2) 1.0 10 (4.1) 1.0
User 9 (5.7) 2.03 (0.70-5.76) 0 - 61 (16.3) 1.33 (0.80-2.22) 76 (18.6) 1.02 (0.69-1.51) 11 (6.3) 2.71 (0.92-7.92)
Academic failures (failed in a
subject) (n=973; 17.7)
Nonuser 175 (21.6) 1.0 192 (35.7) 1.0 238 (26.8) 1.0 64 (3.4) 1.0 4 (1.6) 1.0
User 59 (37.6) 2.10 (1.36-3.23) 28 (43.8) 0.99 (0.55-1.77) 168 (44.8) 1.64 (1.18-2.29) 28 (6.8) 0.82 (0.41-1.63) 17 (9.8) 2.44 (0.5-11.3)
Lifetime tobacco use (n=485; 8.8)
Nonuser 10 (1.2) 1.0 1 (0.2) * - 22 (2.5) 1.0 48 (2.6) 1.0 10 (4.1) 1.0
User 31 (19.7) 27.19 (10.51-70.3) 2 (3.1) - 136 (36.3) 38.09 (17.8-80.91) 140 (34.2) 18.16 (10.6-31.16) 85 (48.9) 35.21 (13.5-91.9)
Psychological distress
Nonuser (mean±SD) 17.85±7.70 1.0 17.98±8.36 1.0 16.98±7.61 1.0 16.20±6.87 1.0 18.48±7.18 1.0
User (mean±SD) 20.68±9.22 1.03 (1.01-1.06) 22.83±8.69 1.02 (0.98-1.06) 18.06±8.74 1.01 (0.99-1.03) 18.76±8.40 1.03 (1.01-1.04) 20.14±7.43 1.04 (1.01-1.08)
Suicidal thoughts (n=1188; 21.5)
Nonuser 168 (20.7) 1.0 125 (23.2) 1.0 149 (16.8) 1.0 334 (17.8) 1.0 57 (23.5) 1.0
User 49 (31.2) 1.20 (0.72-2.01) 32 (50.0) 2.15 (1.11-4.16) 101 (26.9) 2.04 (1.36-3.06) 114 (27.9) 1.47 (1.03-2.10) 59 (33.9) 1.04 (0.54-2.01)
Suicidal attempts (n=227; 4.1)
Nonuser 25 (3.1) 1.0 20 (3.7) 1.0 28 (3.1) 1.0 62 (3.3) 1.0 12 (4.9) 1.0
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User 17 (10.8) 2.01 (0.88-4.52) 11 (17.2) 1.91 (0.74-4.90) 9 (2.4) 0.50 (0.19-1.32) 27 (6.6) 1.17 (0.61-2.24) 16 (9.2) 1.91 (0.64-5.68)
Menon, et al.: Academic streams and alcohol use in colleges

Figures in bold indicate significant OR for comparison of alcohol users vs non‑users in examined variables. *OR not examined as baseline prevalence of tobacco use in nursing was 0.5%. CI – Confidence interval;
OR – Odds ratio; SD – Standard deviation

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Menon, et al.: Academic streams and alcohol use in colleges
institutions, and engagement in physical activity have been
reported to influence alcohol use.[13]
Among our students, relatively lower rates of alcohol use
have been found in students pursuing nursing and medical
streams and higher rates among those in engineering and
“other streams” (fisheries/law). The overall rates of alcohol
use across examined academic streams were lower than
those reported from colleges in HIC.[4‑6] Students pursuing
medical and nursing also showed lower severity of alcohol
use signified by both lower mean ASSIST scores and fewer
hazardous users. The lower rates in academic streams
where students are more likely to be knowledgeable of
poor outcomes linked to alcohol use have been reported.[26]
Alcohol consumption among students in the medical/nursing
stream has added importance as their attitudes may
influence their professional decisions about clients seeking
help for alcohol‑related problems.[23]
Male students in our study across all courses had a
significantly higher rate of alcohol use as has been
consistently reported.[4,5] Also, across courses, those from the
Muslim community had a low rate of alcohol use. Our finding
adds to the robust evidence that religiosity influences use
of substances including alcohol.[5] Increased age was a risk
factor for consumption of alcohol only among our students
pursuing engineering and arts and sciences. Previous studies
have also reported that effects of age are often blurred by
course, academic year, and workload.[27] Place of residence
showed an inconsistent association, with urban residence
increasing risk among students pursuing medicine and other
courses, and rural residence for students in arts and science.
Family structure and socioeconomic category did not
influence risk of alcohol use in any of the examined courses.
Previous studies which have examined the association
of these sociodemographic variables with alcohol use in
colleges have often reported different conclusions.[5,13]
Use of tobacco was robustly linked to alcohol use among
students in all academic streams. This finding has been
consistently reported prior.[4,5] Academic failures were
associated with alcohol use only among students pursuing
engineering and medicine suggesting that academic failures
in streams with greater intensity of course effort may
influence alcohol use. Among our students, psychological
distress and suicidality did not show a consistent
relationship across all examined academic streams. Most
studies report psychological distress and suicidality to be
associated with substance use but this relationship is often
mediated by other variables such as negative life‑events,
perceived social support, parent–child conflict, academic
performance, and financial stability.[5,28,29]
The study had its limitations. The findings were based on
self‑report and no formal interview was conducted. This
study was cross‑sectional. Therefore, no inference regarding
Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021
the direction of causality of examined correlates can be
made. Factors such as peer drinking levels, alcohol‑related
attitudes, and social affiliation, which are known to
mediate the relationship between alcohol use and college
environment, were not examined. Suicidality was assessed
by limited questions. However, the strengths include
assessment of a large sample across various academic
streams making our findings generalizable within Kerala.
Structured instruments were used where possible.
Our finding has public health implications. Exposure
to a heavy drinking environment has been known to
increase drinking. However, we are not suggesting that all
students exposed to such norms will experience alcohol
use. A multitude of psychological (e.g., distress), social
(e.g., religion), and individual factors (e.g., impulsivity)
have been shown to moderate the influence of the college
environment.[30] Currently, college‑based interventions
in India consider college students as sharing a single
homogenous culture. Our study suggests that this may not
be the case, and intervention programs need to take into
account the environment, student campus culture, and
various individual factors to improve effectiveness. Future
research needs to focus on the development of integrated
intervention models, which incorporates all these domains.
CONCLUSION
Our study suggests that alcohol use and its psychosocial
correlates vary among students pursuing various academic
streams. Hence intervention strategies need to be refocus
to target academic streams with higher prevalence.
Acknowledgments
The authors wish to thank all the staff at all participating
colleges who provided administrative and logistic support
for the research project, and Mr. Ajayakumar and the team
who helped with data entry. We also thank all students who
kindly took part in this survey.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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34 Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021