Consumption of alcohol and drugs and school absenteeism among high school students of public schools.

OBJECTIVE
To evaluate the relation between the consumption of alcohol and other drugs and school absenteeism in high school students of public schools in the 30 days prior to data collection.


METHOD
Cross-sectional study of quantitative character conducted from May to September 2017, with 282 high school students of public schools of Mossoró-RN. We used a closed questionnaire with questions about drug consumption as our instrument of analysis. We performed hierarchical binary logistic regression by using the SPSS 20.0.


RESULTS
In bivariate analysis, the relation between absenteeism and drug consumption patterns proved to be significant to those who engage in heavy episodic drinking of alcohol and in the use of tobacco, inhalants and marijuana. The adjusted regression model only included the variables tobacco and heavy episodic drinking of alcohol.


CONCLUSION
The hierarchical binary logistic regression analysis corroborated with absenteeism outcomes, explaining it in 12.3% of cases.


INTRODUCTION
Different patterns of substance consumption that promote some kind of altered state of consciousness accompanied the history of humanity according to the cultural production of each people at certain times, being used in several contexts, from devotional and religious rituals, festive and recreational events, to even alternative therapies (1) . Until the mid-18th century, the use of drugs was moderate and balanced, but since the Industrial Revolution people started to see it as a commodity (2) .
Nowadays, the abuse of psychoactive substances (APS) is associated with severe social, educational, safety and public health issues around the world. The first experience of use usually occurs in adolescence and has several motivations, such as the easing of existential crises, the formation of social and affectional bonds, and the search for fun (3) . One must also highlight the motivations that stem from past experiences within the biopsychosocial environment, such as the fragility of social and family bonds, the emotional distance between adolescents and their parents and/ or legal guardians, and the characteristics of this particular life phase, such as impulsivity and curiosity (4)(5) . This abusive consumption of drugs has several negative consequences, among them, there are problems such as school absenteeism and early school dropouts (6) , which among other things, reflect the weakening of health promotion processes.
The existence of a complex network comprising social, economic, environmental, structural, emotional and psychological factors that affect the full exercise of citizenship by adolescents is notorious. Social spaces attended by adolescents usually lack leisure venues, cultural and sport incentives focused on this particular audience, which urge for alternative and productive occupations. The bad distribution of income and the consequent inequality of access to social goods determine the life conditions of these young people, leaving them vulnerable to drugs. At this stage, adolescents have greater difficulty of access to health care, education and social assistance services that allow them to have proper conditions to attend environments where it is common to experience APS. Features that hinder the development of adaptive responses to situations of crisis are responsible for these vulnerabilities (7) .
In Brazil, several research show a growing trend for drug use among young people and adolescents. The last survey that addressed students from Brazilian public and private schools held in 2010 showed that a quarter of participants had already used illicit drugs before. Regarding alcohol, 60.5% reported having used it before, 42.4% reported having used it in the last year, and 21.1% reported having used it in the last 30 days before the interview. As for tobacco, 16.9% reported having used it already, 9.6%, in the past year, and 5.5% in the last month (8) .
School absenteeism and school dropout have constantly been pointed out as major problems associated with drug abuse (9) , but we also perceive school absences, grade retention, learning difficulties as students' lack of commitment towards their formation (6) . Longitudinal studies associate it with high unemployment rates, health problems, legal penalties and family and social conflicts (10) .
Some associate social inequality and the lack of equal educational opportunities to higher risks of drug abuse and the problems caused by it (11)(12) . Despite public schools favoring the building of resilience in adolescents, they lack better structure, adequacy to curriculum matrices, more qualified teachers and better pedagogical approaches on this particular issue.
Considered a severe public health problem (6,11) , school absenteeism associated with drug abuse requires a joint intersectoral and interprofessional collaboration to find more complete and complex solutions for the problem. The relation between health and education, especially at primary care level, requires knowledge, skills, creativity and openness to work with this audience. Strategies such as the Programa Saúde na Escola (PSE), based on the articulation between these two sectors, aim at developing citizenship within these adolescents.
With this in mind, professional nurses have been protagonists in conducting programs such as the PSE, as part of their job actuation is the organization of programs and actions, indicating they know how to address the issues implied in this field. In this way, diagnosing the relation between absenteeism and drug use among adolescent students of public high schools is essential for professionals that seek to work with prevention and health promotion in the school environment.

OBJECTIVE
To evaluate the association between the consumption of alcohol and other drugs with school absenteeism in the 30 days before data collection carried out with high school students of a public school of Mossoró, Rio Grande do Norte.

Ethical aspects
This research was approved by the Research Ethics Committee (CEP) of the Universidade do Estado do Rio Grande do Norte (Uern). Before data collection, we presented the objectives of the research, its risks and benefits, how data collection would work, and ensured the anonymity and confidentiality of data. Those who wanted to participate had to sign the term of Free and Informed Consent, and to take two copies of the Free and Clarified Consent Term (TFCC) home to collect the signatures of their parents or legal guardians. All provisions contained in resolution No. 466/2012-CNS were followed.

Design, local and period of study
Cross-sectional study, of survey cross-sectional type and quantitative character, carried out from May to September 2017 with adolescent students of public high schools of the city of Mossoró, Rio Grande do Norte. The study approached 17 state schools and one federal school. To ensure anonymity, both school types were referred to as public schools.

Population and sampling
The study population comprised adolescent students of public high school of both sexes. The definition of the sampling design Consumption of alcohol and drugs and school absenteeism among high school students of public schools Soares FRR, Farias BRF, Monteiro ARM.
of the survey was proportional to the number of enrollments per school, to the disposal of students per classes and shifts, ensuring the representativeness of the population in a stratified random sample. A formula to calculate samples for finite populations was used, with a 95% confidence level, 5% of precision level, and expected amount of accuracy and errors of, respectively, 25% and 75% (8) , thus obtaining a sample with 282 individuals. To achieve n, data collection was carried out with 334 participants. The inclusion criteria was the following: students had to be enrolled in the high school classes of the selected institutions and they had to be between 12 and 17 years-old. We defined the following characteristics as exclusion criteria: students who despite being enrolled, did not attend classes; students who were absent in the days of data collection; students who had any kind of temporary or definitive impairment that prevented them from answering to the questionnaire; or any mental disorder that implied cognitive inability.

Study protocol
To avoid selection bias, all students who agreed to participate in the study could answer to the questionnaire, which was later stored in boxes-files identified by room, shift, class and school, and that after both qualitative and internal reviews, underwent random selection with the aid of a spreadsheet with random numbers in Microsoft Excel version (version 2013).
We used a closed, autofill and anonymous questionnaire, adapted from the World Health Organization (WHO) to be used in Brazilian national surveys on students' consumption of psychotropic drugs carried out by the Brazilian Center of Information on Drugs (Cebrid) [Centro Brasileiro de Informações sobre Drogas], being called annex 3 in the last national survey (8) .
After data collection, all questionnaires were submitted to two reviews, one of qualitative character, which comprised internal response consistency tests, discarding the ones in which adolescents answered "no" when referring to lifetime use and "yes" to use in the last month; and another internal one, which discarded questionnaires in which participants replied positively to a question about a fictional drug (over-reported usage). A total of 55 questionnaires were excluded after undergoing the internal response consistency review and seven other questionnaires that had false-positive results, totaling a sample of 282 individuals.
The outcome variable for this study was the question 6A, while the predictor variables were the questions 7J, 9C, 11C, 12C, and 16C. For the purposes of statistical analysis, we adapted the questionnaire in a way that we could only get yes/no answers. The Chart 1 presents the appropriateness of the variables for this study.

Analysis of the results and statistics
Initially, the descriptive analysis of the data was carried out, especially of data specific questions on the participants' issues and social habits, through distributions of absolute and relative frequencies (%). Then, cross tabulation with the Chi-square test was conducted. The Phi coefficient and the odds ratio were calculated to observe the strength of these relations and ensure better variable hierarchy.
After the bivariate analysis, Phi coefficient values were used to determine the hierarchical order of the variables on school absenteeism rates to be applied in logistic regression. From this analysis, the following hierarchy between the characteristics was established: 9C 7J 11C 12C 16C. Then, the hierarchical binary logistic regression through an advanced method. For all statistical tests performed, the significance level was 5%.

RESULTS
From the 282 participants, 57.8% (163) were female, 69.5% (196) were above 16 years, the average age of participants being 17 (±1.08 years). School absenteeism in the last 30 days before data collection was of 36.2% (102). Table 1 presents a descriptive overview of lifetime consumption patterns and consumption patterns in the last 30 days.
Lifetime consumption of alcoholic beverages accounted for 79% (223), the first experience with alcohol happening at the age of 14.7 years (± 2.1 years) in average; 43.2% (122) reported having consumed alcohol in the last 30 days, and 32.2% (91) reported having drank from 1 to 5 days in the month; 33.7% (95) of participants reported the practice of heavy episodic drinking (HED), characterized by the excessive amount of alcohol consumed in one given episode, when people have five or more alcohol drinks within a period of time, regardless of the frequency of use. The mainly consumed beverages were beer or drafted beer (69.8%), vodka (56.8%), whiskey (36.7%) and "batida" or "caipirinha" (33.8%).
Concerning tobacco, 23.8% (67) had already used it in their lifetime; however, the percentage of consumption in the last 30 days was of 7.4% (21), while the average age for its first consumption was of 14.3 years (±3.1 years). From the interviewed, 16.7% (47) had used some inhalant product to get high before, their first experience with it being at age of 15.1 years (±2.8 years) in average; in the last 30 days, 3.9% (11) reported consumption of"loló" or "lança perfume", also showing a percentage of 68.1% (32) of use in lifetime.
From all the interviewed students, 14.5% (41) have tried marijuana before at an average age of of 15.7 years (± 1.5 years); the percentage of consumption in the last 30 days was of 6.7% (23). When it comes to cocaine, 6.4% (18) of the interviewed have already tried before at an average age of 16.8 years (± 1.25 years); the percentage of use in the last month was around 2.5% (7) .  (8) . Table 2 presents the results of the bivariate individual analysis of each predictor variable associated with its outcome. The relation between school absenteeism and patterns of drug consumption as predictors were significant to those who practice heavy episodic drinking (HED) [X² (1) = 12.789; p<0.0001] with association degree of 21.3%; tobacco [X² (1) = 19,709; p<0.001], with association degree of 26.4%; inhalants (p<0.05) with association degree of 17%; and marijuana [X² (1) = 6.617; p=0.010] with association degree of 15.3%.
The chance of students who did not practice HED being absent in class without parental consent was two and a half times lower than in the group that practiced it [OR = 2.5; 95%CI = 1.5 -4.2]. Regarding the consumption of tobacco, that chance was 8. The odds ratio of use of cocaine was not significant in the sample studied. It should be noted that patterns of drug use reviewed here referred to use over the 30 days prior to data collection. Table 3 summarizes logistic regression. The question 9C ("Have you smoked any cigarette over the past 30 days?") was a significant predictor (OR = 0.146; 95%CI = 0.047 -0.455), as well as the question 7J ("Have you drank more than 5 doses or more of alcohol in the same occasion over the past 30 days?") (OR = 0.478; 95%CI = 0.280 -0.815). The template containing these two issues proved to be adjusted[X² (2) = 26.501; p<0.0001, R² = 0.123], which explains the 12.3% outcome of the cases.

DISCUSSION
School absenteeism is the unjustified absence of students in schools, being a relevant issue in the normal process of schooling, as it implies students' presence in the classroom. Both school absenteeism and school dropout have been considered serious public health issues and some authors even perceive them as part of a crisis (6,11,13) .
Sometimes it is possible to note a significant association between school absenteeism, low school performance, and school dropout with the use of psychoactive substances, particularly alcohol, tobacco, and marijuana (14) . These school problems can lead to suicide attempts, drug addiction, cerebrovascular accidents and diseases in adulthood (14) , which in the long term, can prevent these students from entering the job market and having more job opportunities (15) , besides also developing mental disorders, criminal (4) , violent and aggressive behaviors, and sexual behaviors of risk (16) . In this study, the school absenteeism rate was of 36.2% (102), i.e. more than a third of the young people interviewed put themselves at risk because of this issue.
The consumption of alcohol and other drugs usually starts during adolescence and it has been occurring earlier and earlier (10,17) ,  considering that at this phase, brain structures responsible for temporal perception and impulse control are still maturing (10) , which can decisively affect human development and the building of the skills necessary to school learning. When compared to the last national survey on the consumption of psychotropic drugs among primary and secondary school students of public and private educational networks in 27 Brazilian state capitals in 2010 (8) , the studied population showed higher rates (79%) for the consumption of alcoholic beverages in their lifetime when compared to Brazilian students (60.5%) and students from Natal, the capital of Rio Grande do Norte, which was also the state chosen for this study(62,95%).
This growth does not corroborate with the decreasing trends obtained by national surveys carried out between 2004 and 2010. Another concern is the fact that more than a third of the interviewed young people reported practicing HED, which can lead to serious complications, not only of social, physical and psychological order, but also concerning public security. In addition, it increases the use of inhalant, being associated with the consumption of marijuana and cocaine (18) .
We also observed a growth in the consumption of tobacco and its derivatives when comparing our results with the ones from previous studies (8) , as we obtained values of 23.8%, while surveys conducted nationwide and statewide showed 16.9% and 15.5%, respectively. This increase in tobacco use associated with precocity of the first experimentation (14.3 ± 3.1 years) substantially increases students' risk of developing respiratory problems, ischemic heart disease, chronic non-communicable diseases and cancer in the lungs, bronchus and trachea, as it implies the maintenance of these habits in adulthood (19) .
The use of inhalants among the interviewed adolescents also showed higher indexes when compared to the ones of other cities/regions of the country. A study carried out in 2017 in the city of Belo Horizonte (20) showed a percentage of 7.9% for lifetime use of inhalants, while in Aracaju, in a study conducted in 2015, this percentage was of 8% (21) . This type of psychoactive substance is addictive and can lead to brain damage, heart problems, liver problems, kidney failure and death, including suicide, besides also contributing to personality and mood disorders and anxiety, as well as to broader social problems such as violence and vandalism (20) .
The rate of people who had already tried marijuana and cocaine was also higher than the ones found in surveys conducted nationwide and in the city of Natal by 2010 (8) . The consumption of these drugs during adolescence is associated with greater social, legal and family problems, hindering the social and neurological development of these groups (9) .
Regarding the average age when people usually have their first experiences with drug consumption, we found that tobacco and alcoholic beverages were first to be used by the studied population, followed by the other substances here mentioned. This information corroborates with the argument that those who start consuming these first two tend to start using other stronger substances (10)(11)(12)(13)(14)(15).
The significant association between the consumption of alcohol (p<0.0001), tobacco (p<0.0001), inhalants (p=0.005) and marijuana (p=0.010) with school absenteeism over the past 30 days before data collection corroborated with data from national and international studies (6,16).
We found similarities between the association between marijuana consumption and school problems and studies conducted in Australia (15) , France (14) , and the United States of America (16) . These studies perceive this association between marijuana and alcohol and/or tobacco as a behavior of risk.
The use of inhalant drugs is potentially dangerous to the adolescents' physical and mental development (20) . In Brazil, the practice of HED increased the risk of consumption of these drugs [OR = 5.02; 95%CI 2.57 -9.81] and also the consumption of marijuana and cocaine (22) .
A study carried out in South Korea (4) indicated a strong association between the use of licit and illicit drugs with socially disadvantaged families. Research already carried out in the United States of America (14) demonstrated the relationship between drug abuse, poverty and racial issues.
The hierarchical binary logistic regression analysis that proved to be adequate to evaluate school absenteeism in the 30 days preceding data collection included only two predictor variables: HED and the consumption of tobacco in the last month. This model explained the unjustified absences without the permission of parents and legal guardians in 12.3% of cases. This information contributes to the previous discussion on the need to consider the contextual issues to understand the phenomenon of the abuse of psychoactive substances and its consequences, including the ones that affect school.
A North American study reported the frequent use of tobacco as a risk factor for early school dropout (9) . A Brazilian study published in 2014 (6) indicated that the combined use of alcohol and tobacco affects school related matter, similarly to what happens with the use of illicit drugs. Research conducted in public schools of Aracaju-SE and published by 2017 (22) also indicated this combined use as important predictors for problems at school.
Adolescence is a crucial moment in human development and problems caused by the abuse of psychoactive substances impact the future of individuals, especially at the school, leading to absenteeism and school dropout as consequences of public health problems, thus requiring interprofessional and intersectoral actions to address all the risk factors. Besides the bivariate analysis showing that all drugs mentioned, except for cocaine, showed a significant association with unjustified absences, the model including the practice of HED and the use of tobacco accounted for only around 1/8, implying the need to cover the entire context in which these teens are inserted, not only the problems regarding drugs.

Study limitations
This study aimed at all approaching this theme as a whole and at explaining why adolescents missed school without parental consent. We implied the need for more comprehensive studies, i.e., broaden samples and broaden institution spectrum to include private schools, adolescents attending the elementary course and superior education and even those who have decided to dropout from school. Among the limitations of this study, there are the restricted access to classrooms imposed by some schools, the length of the questionnaire, the fact that data collection did not consider the association between the subject's socioeconomic Consumption of alcohol and drugs and school absenteeism among high school students of public schools Soares FRR, Farias BRF, Monteiro ARM. conditions and school absenteeism. As the questionnaire did not address the social and economic contexts, the analysis in this study was not comprehensive enough to assess the cause/ effect relationships between drug use, its determinants and its school consequences, only focusing on school absenteeism.

Contributions to the field of nursing and public health
This research contributes to planning of intersectoral actions on health and education focused on the integral care to adolescent students who use drugs. Recognizing the factors associated with school absenteeism and school dropouts as public health problems should subsidize the action of nurses, especially in primary care and specialized services of psychosocial care, in a interprofessional and multidisciplinary collaboration perspective involving strategies from public and private administration, and from the third sector.

CONCLUSION
In a preliminary analysis, the bivariate relation between school absenteeism and drug consumption patterns has proven to be significant to those who practiced HED and with a history of use of tobacco, inhalants and marijuana. The chance of high school students who did not practice HED missing school without parental consent is two and a half times lower than in the group that did. Regarding the consumption of tobacco, this chance is about 8.8 times higher; as for inhalants and marijuana, it is, respectively, 5.7 times and 3 times higher. The hierarchical binary logistic regression analysis proved to be adequate to address school absenteeism in the 30 days prior to data collection when considering HED and the consumption of tobacco over the last month. This model explained the students' absences without the consent of parents and legal guardians in 12.3% of cases. It is worth mentioning that school problems can both precede the use of substances or proceed the consumption of drugs. Furthermore, the evaluation of these variables without the analysis of social, economic, educational, affective and familiar contexts of adolescents is inconsistent, thus it is important to note that this study is preliminary in the sense of seeking greater explanations for the phenomenon of drug use, its antecedents and consequences.