Abstract(resumo):

This study assessed the factors associated with the use of alcohol among Brazilian graduate students. A cross-sectional survey was conducted with 5,112 graduate students across Brazil between May and July 2022, using an electronic form on the Research Electronic Data Capture (REDCap) platform. The Ordinal Logistic Regression model with cumulative logits was used for the analysis in the R software. There were higher odds of alcohol use among graduate students facing significant difficulties in accessing the internet (OR = 2.25; CI = 1.51–3.38; p = 0.001), those spending more than three hours daily on social media (OR = 1.39; CI = 1.15–1.66; p = 0.005), using various medications (OR = 1.28; CI = 1.07–1.53; p = 0.008) including those for COVID-19 protection (OR = 1.37; CI = 1.00–1.88; p = 0.05) and psychotropic drugs without prescription (OR = 1.91; CI = 1.26–2.89; p = 0.0023), as well as tobacco (OR = 2.93; CI = 2.28–3.77; p < 0,001), cocaine (OR = 4.29; CI = 2.46–7.48; p < 0.001), and cannabis (OR = 2.19; CI = 1.78–2.71; p < 0,001). Being female (OR = 0.66; CI = 0.55–0.79; p < 0.001) and attending online classes equivalent to in-person ones (OR = 0.66; CI = 0.54 – 0.81; p < 0.001) were protective factors.

Keywords(palavra-chave):

Excessive Drinking; Researchers; Mental Health; Alcohol Drinking; COVID-19.

Content(conteúdo):

Introduction

Universities are recognized for their diversity and respected for their intellectual knowledge but are also environments where students are susceptible to factors that can impact their mental and behavioural health 1,2. Among these factors, alcohol consumption is a considerable variable, especially among graduate students who face distinct challenges in their academic journey 3.
Alcohol is the most widely used socializing psychoactive substance worldwide 3,4,5,6. Abusive alcohol use and dependence are associated with increased risk of morbidity, mortality, and disabilities, especially among the younger and more educated populations 7,8,9.
Graduate students are immersed in research, often have multiple responsibilities, and have the pressure to academically perform to a high level which presents a distinct profile that justifies a more in-depth and targeted analysis 10. The complex nature of graduate students' lives can impact students' physical health as well as result in symptoms of anxiety, depression, and social isolation, and promote substance use, regardless of legality, as a coping mechanism 11.
Evidence has consistently highlighted the importance of investigating alcohol use patterns in academic contexts 4,12. A study conducted among postgraduate students in the United Kingdom reported a 17% increase in harmful alcohol consumption within this population during the pandemic 13 . However, there is a notable gap in understanding the specific determinants associated with aspects of mental health among master's and doctoral students 2,14, as well as consumption patterns and related factors 15.
The study aimed to address this knowledge gap by assessing not only the prevalence of alcohol use among Brazilian graduate students, but also by identifying specific factors associated with these patterns, such as the student’s academic level, health, cultural contexts, and sociodemographic characteristics. Understanding these determinants is crucial for the development of health promotion strategies, brief interventions, and more effective prevention tailored to the specific needs of this population, who represent the major force of Brazilian research. For these reasons, the study sought to identify factors associated with alcohol use among Brazilian graduate students.
Methods
This is a cross-sectional, analytical, and observational study employing a quantitative survey approach.
The present study is part of a matrix project, ‘The mental health of Brazilian graduate students in times of Pandemic: harms and promotion strategy’. The project follows the Code of Ethics of the World Medical Association (Declaration of Helsinki) and was approved by the Research Ethics Committee under Protocol CAAE: 56048822.9.0000.5393.
Study Location
The study was conducted online on the Research Electronic Data Capture (REDCap) platform and was carried out from May to July 2022, across Brazil. It followed the recommended guidelines of the Reporting of Observational Studies in Epidemiology (STROBE) 16 and was guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) 17.
According to data from the Coordination for the Improvement of Higher Education Personnel (CAPES), before the data collection period of this research, there were 388,629 postgraduate students registered in 4,565 postgraduate programs (master's and doctorate) in 498 public and private higher education institutions (HEIs) in Brazil 2019.
Sample and Data Collection
Sample Size Calculation:
A prevalence of 50% was considered for the sample size calculation. It is important to highlight that when there is no specific information about outcome prevalence, as is the case with the outcome of the present study, statistical analyses estimate that calculating for 50%, the obtained sample size will be sufficient for any prevalence value18.
Given a reliability of 1.5% and a confidence interval of 95%, we sought to obtain a minimum sample of 4,222 participants. As statistical practice does not set a specific percentage of losses that should be universally accepted, we estimated a 20% loss rate to account for a high likelihood of students not responding or responding incompletely to the survey due to the specific characteristics of the population under study (such as the number of activities).
To recruit participants, an email was sent to all Brazilian graduate programs, urging them to circulate an invitation letter to their graduate students with a link for accessing the electronic form on the REDCap platform. The list of graduate programs was obtained from the Sucupira platform of the Brazilian National Graduate System19. The invitation was sent to graduate programs because no system is available in Brazil for making direct contact with graduate students.
When accessing the link, participants were invited to enter personal background and to read the consent form and give their consent to the use of anonymized data.
Inclusion and Exclusion Criteria
The inclusion criteria required participants to be graduate students aged 18 years or older, of any gender, residing in Brazil, and having internet access. The exclusion criterion was the incomplete completion of the questionnaire.
Sample and Data Collection Procedure
A total of 6,671 graduate students accessed the form, the sample consisted of 5,334 graduate students who met the eligibility criteria and completed the form in full.
For data collection, a previous list was used containing records of all Graduate Programs from public Higher Education Institutions in Brazil. The email list of Graduate Programs was obtained from the Sucupira Platform, which is a system for collecting information, analyses, and evaluations and used as a standardizing basis for the Brazilian National Postgraduate System.
Subsequently, an email was sent to all Graduate Programs requesting that an invitation letter be sent to all graduate students, along with the link to access the data collection instruments. Thus, all enrolled students received invitations to participate in the research.
To minimize biases inherent in online surveys, Graduate Programs were requested to confirm that they had sent the invitation to their graduate students. A secure data collection platform was used to allow access to the link on mobile devices. In addition, the confidentiality of all information was guaranteed.
Upon accessing the link, participants were directed to read the informed consent form and give their consent for the use of anonymized data. Those who expressed interest in participating, after agreeing to the Informed Consent Form, were directed to the electronic questionnaire where they answered the questions. The outcome variable was alcohol use, which was assessed by the Alcohol Use Disorders Identification Test (AUDIT), and the independent variables included sociodemographic, economic, academic, physical health, mental health, and COVID-19-related information.
Measures
Data collection was conducted through a survey containing sociodemographic information (age, gender, income, sexual orientation, marital status, presence of children, ethnicity/race, religion); academic aspects (current graduate program, which CAPES knowledge area their graduate program belonged to, scholarship status, additional work besides graduate studies, hours dedicated to graduate studies, whether the student had remote classes during the pandemic and whether the student considered the remote classes to be equivalent to face-to-face classes, course suspension, need for extension of deadlines, internet access for academic activities); social media use (social media platforms used, hours per day spent on social media, dissatisfaction with appearance when accessing social media, dissatisfaction with life when accessing social media); physical, mental health, and COVID-19 variables (any health problems, continuous medication use, use of medication without prescription, tobacco use, fear of contracting COVID-19 during the pandemic, COVID-19 immunization status, belonging to a COVID-19 risk group, use of medication without prescription for COVID-19 protection, testing positive for COVID-19, receiving medical care during the pandemic, receiving psychological counselling during the pandemic, diagnosed with a mental health problem, family member diagnosed with a mental health problem, missing activities because of mental health problems, use of psychotropic substances (illicit drug use), use of psychotropic medication without prescription.
The Alcohol Use Disorders Identification Test (AUDIT) is an instrument for assessing patterns of alcohol use. It was developed by the World Health Organization20 and was translated and validated for use in Brazil by Lima et al 21. The AUDIT consists of 10 items about quantity and frequency of use, symptoms of alcohol dependence, and problems related to consumption. The total scores range from 0 to 40 points, with four risk zones identified: Zone I - low risk (0 to 7 points); Zone II - Risk use (8 to 15 points); Zone III - harmful use (16 to 19 points); and zone IV - probable dependence (20 to 40 points). In addition to this classification system, the AUDIT has also been widely used with a cutoff score of eight points (zone II-IV), representing problematic drinking 22.
Statistical Analysis
Upon the completion of data collection, the data was exported to Excel® and was then analysed using the R software 23 with the VGAM package 24.
In the first stage of analysis, variable selection aimed to identify those that were statistically significant (? = 0.05) in the bivariate analysis. In the second stage, the variable selection was performed using the Stepwise method employing the Bayesian Information Criterion (BIC), considering the assumption of parallelism for all variables.
The Likelihood Ratio Test was used to assess the significance of variables at each stage of variable inclusion and exclusion for comparing adjusted models 25. The Ordinal Logistic Regression model with cumulative logits was employed, as the Estimate of Transition Equations (ETE) variable has ordered categories (Zones I-IV of the AUDIT). Considering the number of independent variables analyzed in the model, the proportional odds assumption was adopted. Multicollinearity analysis was performed using the Variance Inflation Factor (VIF) method, with a cutoff point of 5 (multicollinearity issue if VIF > 5). A significance level of 5% (? = 0.05) was adopted for all tests.
Results
Characterization of Participants
A total of 5,112 graduate students from all Brazilian regions participated in the study. There was a predominance of female participants (66.8%), with a mean age of 33.1 years (Standard Deviation = 8.27), unmarried (56.1%), with a monthly income (>4 minimum wages) (86.1%), heterosexual (77.3%), white ethnicity/skin colour (63.4%), without children (75.4%), living in households with three or more people (46.1%), and with no religious affiliation (41.4%).
Regarding academic characteristics, slightly more than half were pursuing a master's degree (56.3%), in courses within the Health Sciences field (23.6%). The majority had remote classes during the COVID-19 pandemic (93.0%), considered remote classes not equivalent to in-person classes (66.5%), experienced few difficulties in accessing the internet (96.0%), were satisfied with remote teaching (54.6%), spent up to three hours daily using social media (71.9%), and had not taken time away from activities in the past year (71.9%).
Regarding the health information of the participants, 16.9% belonged to a COVID-19 risk group, 8.5% reported self-medicating for protection from COVID-19, 39.5% had used some form of continuous medication, and 32.8% used medications without prescription. Regarding the use of psychotropic medications, 22.1% started using them during the pandemic, 19.5% were already using them before the pandemic, and additionally, 8.4% of the participants used psychotropic medications without a prescription.
Among the participants, 8.4% were active smokers, 15.9% used illicit drugs before the pandemic, and 4.3% started using illicit drugs during the COVID-19 pandemic.
Factors Associated with Alcohol Use
Among the participants, 22.6% reported not having used alcohol in the last year; 29.5% reported drinking alcohol once a month or less; 29.3% reported drinking alcohol two to four times a month; 14.8% reported drinking alcohol two to three times a week, and 3.8% reported drinking alcohol four or more times a week.
A possible explanation for this finding is that graduate students who perceived remote classes as equivalent to in-person ones were more likely to adopt positive adaptation strategies, which, in turn, led to lower stress levels and a reduced reliance on alcohol as a coping mechanism. Bahji et al (2024) in their study with Canadian graduate students, support the findings of our study, as students who exhibited protective strategies also showed lower rates of high-risk alcohol use. However, this relationship should be further explored in future studies.
Regarding the classification of alcohol consumption (AUDIT), 78.2% of participants were classified in Zone I (Low-risk), 16.3% in Zone II (Risky use), 2.9% in Zone III (Harmful use), and 2.6% in Zone IV (Probable dependence).
Women (34.2%) and participants who considered remote classes to be equivalent to in-person classes (33.7%) were less likely to be classified as problematic drinkers (Zones II-IV of AUDIT) (Table 1).
The risk factors for problematic drinking (AUDIT) included experiencing significant difficulties accessing the internet (OR = 2.25; CI = 1.51–3.38; p = 0.001), spending more than three hours per day on social media (OR = 1.39; CI = 1.15–1.66; p = 0.005), and requiring time off from activities in the past year (OR = 1.32; CI = 1.10–1.58; p = 0.003) (Table 1).
Participants who used over-the-counter medications (OR = 1.28; CI = 1.07 – 1.53; p = 0.008), those who used unprescribed medications for COVID-19 prevention (OR = 1.37; CI = 1.00–1.88; p = 0.05), and those who used psychotropic medications, whether without a prescription (OR = 1.91; CI = 1.26–2.89; p = 0.0023) or with a prescription (OR = 1.29; CI = 1.06–1.57; p = 0.0097), had higher odds of problematic alcohol use compared to low-risk individuals (Table 1)."
Active smokers (OR = 2.93; CI = 2.28–3.77; p < 0.001), those who used cocaine before the pandemic (OR = 4.29; CI = 2.46–7.48; p < 0.001), and cannabis (OR = 2.19; CI = 1.78–2.71; p < 0.001) had higher odds of being classified as problematic drinkers (AUDIT) (Table 1).

[Table 1]?

Discussion
The study investigated the factors associated with alcohol use among Brazilian graduate students. 77.4% of the participants reported that they drank alcohol and 22.6% drank alcohol problematically.
Regarding the use of alcohol by graduate students, a similar study 3 showed that a similar percentage of 1,147 undergraduate students in the health field were at low-risk (AUDIT). Although the highest percentage of participants in this study were in the low-risk Zone, such behaviour still presents a detriment to health, including an increased risk of mortality, particularly from cardiovascular causes 26.
Being female was identified as a protective factor, as supported by the literature 6,8, indicating lower alcohol consumption among women. It is important to consider that the association between being a woman and lower alcohol consumption has multifactorial causes, possibly involving a complex interaction of factors such as biological, socio-cultural, and genetic factors3.
Those who reported that they considered remote classes to be equivalent to in-person classes had lower odds of alcohol use. Being physically present in face-to-face classes is often associated with more intense social interactions, such as events and extracurricular activities. Participating remotely may reduce social pressure and provide greater schedule flexibility, aspects that may be reflected in lower alcohol consumption 27
Those who reported many difficulties accessing the internet and who used social media for more than three hours daily had higher odds of alcohol use. On the other hand, we have technological resources derived from modernization and internet access and all the benefits stemming from it. However, excessive use of technology, especially among young people, can lead to dependency, which can lead to the development of mental disorders, sleep disturbances, irritability, social distancing, and the use of alcohol 28, 29.
Frustrations related to lack of access, or inadequate access to the internet can be a factor that leads to using alcohol and other drugs 30. Furthermore, daily use of social media can be both a risk or protection for alcohol use and is related to economic, social, and personal factors 29. The use of the internet, especially social media, contributes to socializing, and conducting research; however, isolation, stress, and uncertainties about the future may have impacted the increase in alcohol use 31, which may have also affected graduate students during the pandemic.
During the pandemic, strategies such as remote learning and the increased use of social media platforms became essential for maintaining academic activities and social interactions 32-34. These tools played a central role in enabling continuity of education and mitigating social isolation among students. However, disparities in access to digital technologies, such as limited internet connectivity, may have contributed to vulnerabilities among certain groups. In the present study, lack of internet access was associated with a higher risk of alcohol consumption, which raises the need to further explore how digital exclusion may intersect with risk behaviours in the post-pandemic context.
Missing activities in the past year due to not feeling well was associated with alcohol use among participants. With postgraduate students, there is stress and uncertainty about the future, and pressure to produce knowledge, and to complete research all of which have contributed to a mental health crisis that was already evident before the pandemic. Using psychoactive substances generates a sense of "well-being" and relaxation. Alcohol is easily accessible, socially accepted, and widely promoted in society. Therefore, it is necessary to pay close attention to the physical, mental, and social needs of graduate students 35.
Participants who used over-the-counter medications had higher odds of alcohol use . With postgraduate students, alcohol may be used as a coping mechanism for stress stemming from academic pressure, especially related to publications, deadlines, workload, and competitiveness 36. The consequences of graduate students' workload overload may also lead to the use of medications without a prescription 37.
The inappropriate use of medications can result in serious health consequences, such as dependency and adverse events that can be fatal 38. It is observed that the higher the level of education, the more prevalent self-medication practices are, among other reasons, due to the knowledge and availability of information regarding signs and symptoms of diseases and therapeutic possibilities. Such resources provide greater confidence in self-medication 39, 40. Additionally, it is noted that self-medication practices in university settings are more frequently identified in those who study in the healthcare field, especially due to the pharmacokinetic and pharmacodynamics knowledge of medications 41.
Participants who used medications for COVID-19 prevention had higher odds of alcohol consumption. It is worth recalling that in the first quarter of the pandemic, there was an almost 200% increase in the consumption of medications and vitamins 42. Especially vitamins, antivirals, and dewormers were excessively consumed, even though there was no scientific evidence for the treatment of COVID-19 43. Alcoholic beverages were also promoted through fake news as a potential prevention for COVID-19 44, which may have influenced the increased use of alcohol and medications to protect against COVID-19 among graduate students.
Participants using psychotropic medications with and without prescription had higher odds of alcohol use. Alcohol use impacts the physical and mental health of the user, increasing dependency and the likelihood of developing mental health problems 27. The use of psychotropic medications by graduate students may be related to self-medication of symptoms of depression, anxiety, stress, and insomnia frequently identified in people who use psychotropic medications, regardless of prescription 14.
Medications prescribed to treat symptoms of mental distress can be stored and misused without proper medical supervision 45. It is important to emphasize that the combined use of psychotropic medications with alcohol can negatively impact health and increase the risk of death, including by suicide 14.
The increased risk of alcohol consumption among smokers underscores the need for targeted care for this population. Research with health science undergraduates identified a relationship between the use of cigarettes and alcohol, even though the percentage of smokers was low 3, similar to the finding of the present study. The negative association of these substances, in addition to increasing dependency, contributes to a higher occurrence of malignant cardiovascular events, cancer, increased morbidity, mortality, and disabilities 6, 9
Those who used cocaine and cannabinoids before the pandemic had higher odds of alcohol use, and such a relationship between legal and illegal drugs is well documented in the literature 6, 46. The use of illicit drugs has increased by over 20% in the last decade, with the younger population being the most susceptible to use, as well as the most likely to develop mental disorders associated with drug use 46.
Research across different countries on alcohol and drug use during the pandemic identified that more than 60% of the countries reported an increase in alcohol use, and 42% reported an increase in cannabis use, including both marijuana and synthetic cannabinoids 46.
In the academic environment, where graduate students are situated, the use of substances to relieve tension and stress is perceived as a coping strategy, which may have been exacerbated during the most critical phase of the COVID-19 pandemic. However, during the quarantine that happened in most parts of the world and the closure of venues serving alcoholic beverages during lockdowns, some problematic aspects emerged, such as alcohol withdrawal and toxicity 47.
The findings of this study should be interpreted in light of its limitations. The first limitation concerns the cross-sectional design, which does not allow for establishing causation. Additionally, despite the large sample, there was a risk of selection bias, as volunteers may have been concerned about their mental health and may have had different characteristics from the general population. Finally, self-administered questionnaires may introduce recall errors and response bias, as participants may be reluctant to disclose sensitive or embarrassing information 48-50. Despite these limitations, this study strongly points to the high vulnerability of graduate students to alcohol use and its consequences.
This study examines specific factors associated with alcohol use patterns during the COVID-19 period. By identifying key behavioural and contextual factors linked to alcohol use among Brazilian graduate students, this study contributes essential evidence to guide targeted prevention strategies and health policies within academic settings.
Financial support
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001e pelo Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq): Processo: 309958/2023-7.
Acknowledgments
The authors are grateful to the university and participants involved in this study.
*Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brazil (CAPES; Finance Code 001).
**Scholarship of the Coordination for the Improvement of Higher Education Personnel (CAPES) – CAPES/ PRINT/ EERP - University of São Paulo /University of Birmingham UK.
Miyeko Hayashida e Jonas Bodini Alonso - for his assistance in the analysis of data from this study.
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