binge drinking among arab/chaldeans: an exploratory study

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Binge Drinking Among Arab/Chaldeans:An Exploratory StudyCynthia L. Arfken a , Darlene Owens b & Manal Said ca Department of Psychiatry and Behavioral Neurosciences , WayneState University , Detroit , Michiganb Southeast Michigan Community Alliance , Taylor , Michiganc Arab Community Center for Economic and Social Services ,Dearborn , MichiganPublished online: 06 Dec 2012.

To cite this article: Cynthia L. Arfken , Darlene Owens & Manal Said (2012) Binge Drinking AmongArab/Chaldeans: An Exploratory Study, Journal of Ethnicity in Substance Abuse, 11:4, 277-293, DOI:10.1080/15332640.2012.735163

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277

Binge Drinking Among Arab/Chaldeans: An Exploratory Study

CYNTHIA L. ARFKEN Department of Psychiatry and Behavioral Neurosciences,

Wayne State University, Detroit, Michigan

DARLENE OWENS Southeast Michigan Community Alliance, Taylor, Michigan

MANAL SAID Arab Community Center for Economic and Social Services,

Dearborn, Michigan

Focus groups were conducted with young Arab/Chaldeans (N = 82) from different ethno-religious groups (Chaldeans, Orthodox Christians, and Muslims) to explore the potential risk and the pro-tective factors associated with the high level of binge (or episodic heavy) drinking among Arab/Chaldeans reported by general popu-lation surveys. Most of the participants were aware of and knowl-edgeable about the problem in their community. Themes identified as contributory factors consistent across ethno-religious groups included the availability of alcohol, the importance of family, con-formity to group behavior, and social reasons. Differences included the context for drinking and gender roles. These findings can be used to tailor culturally appropriate interventions.

KEYWORDS binge drinking, alcohol, religion, focus groups, Arab Americans

This research was supported by a grant from Southeast Michigan Community Alliance to Cynthia L. Arfken.

Address correspondence to Cynthia L. Arfken, Department of Psychiatry and Behavioral Neurosciences, Wayne State University, 2761 E. Jefferson, Detroit, MI 48027. E-mail: [email protected]

Journal of Ethnicity in Substance Abuse, 11:277–293, 2012Copyright © Taylor & Francis Group, LLCISSN: 1533-2640 print/1533-2659 onlineDOI: 10.1080/15332640.2012.735163

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278 C. L. Arfken et al.

Alcohol abuse and misuse extracts a substantial societal and personal cost (Harwood, 2000; Harwood & Bouchery, 2001; Horgan, 2001). Prevention and treatment interventions can reduce that burden and increasingly are devel-oped or tailored for different racial and ethnic groups (Alegría et al., 2006; Gil, Wagner, & Tubman, 2004; Ja & Aoki, 1993; Santisteban et al., 2003). These interventions are especially needed as the U.S. population becomes increasingly diverse (Humes, Jones, & Ramirez, 2011; Shin & Bruno, 2003). One minority group for whom interventions have not been developed is Arab Americans, a group who emigrated or whose ancestors emigrated from the Arabic-speaking countries of the Middle East and North Africa (de la Cruz & Brittingham, 2003). Also from the Middle East are Chaldeans, a predominately Iraqi ethnicity with strong ties to the Chaldean Church (an Eastern Rite Catholic Church).

Our previous research using data from the state of Michigan docu-mented that Arab/Chaldeans had high rate of binge drinking (Arfken, Arnetz, Fakhouri, Ventimiglia, & Jamil, 2011). According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), binge drinking is defined as five drinks for a man and four drinks for a women over approx-imately 2 hours, which can raise blood alcohol concentrations to 0.8 (Department of Health and Human Services, National Institutes of Health, 2004) with the Centers for Disease Control and Prevention (2005) modify-ing the definition to be “on an occasion”. This modified definition, and even the general definition of the NIAAA, is at odds with the common definition of binge drinking as a period of extended intoxication lasting at least 2 days during which time the drinker neglects usual life responsibili-ties (Hanson, n.d.) and with the World Health Organization’s definition of it as “a pattern of heavy drinking that occurs in an extended period set aside for the purpose” (Babor, Campbell, Room, & Saunders, 1994, p. 32). This diversity in definitions (Watson, 2011) reflects the different popula-tions served and different goals of survey research and clinical care. As summarized by Room (1977), even the description of drinking patterns and related problems among community-based samples has a richly diverse background.

A different definition of binge drinking is included in the Alcohol Use Disorders Identification Test (AUDIT). This screener asks about drinks on an occasion regardless of impairment or perceived intoxification (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). This simple screener has been shown to be clinically useful in emergency departments and primary care facilities across countries, ethnicities, and gender (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Unfortunately, clinical textbooks use both the clinical definition and the survey research definitions (e.g. Frances, Miller, & Mack, 2005), which confuses the issue. For the current community-based research report, we use the Centers for Disease Control and Prevention’s definition.

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Binge Drinking Among Arab/Chaldeans 279

The Michigan data which identified Arab/Chaldeans as having a high rate of binge drinking were collected as part of the Behavioral Risk Factor Surveillance System, funded and coordinated by the Centers for Disease Control and Prevention (Arfken et al., 2011). In 2007, the state of Michigan added the following question to their ongoing annual telephone-adminis-tered surveys of the general population 18 years and older: “Are you of Arab or Chaldean origin?” Using combined data from the 2007–2009 surveys, the rate of binge drinking in the past month was 17% for self-reported Arab/Chaldeans and 18.7% for non-Hispanic Whites. These rates are comparable with national rates of 17.5% (NIAAA, 2009). However, Arab/Chaldeans were less likely to drink alcohol in the past month than non-Hispanic Whites (45.6% versus 59.4%; p < .05). Thus, the weighted rate of binge drinking among those who drink was 38.2% for Arab/Chaldeans and 31.8% for non-Hispanic Whites. Importantly, the level of binge drinking among non-Hispanic Whites has generated public health concern and calls for interventions (NIAAA, 2009). Thus, the level of binge drinking among Arab/Chaldeans also merits interventions.

According to the 2000 Census, Arab Americans were located in every state of the United States, with the largest concentration in Michigan and the Detroit metropolitan area (de la Cruz & Brittingham, 2003). Detroit also has the highest concentration of households speaking Arabic at home (Shin & Bruno, 2003). The 2000 Census reported that Arab Americans were younger than the general population and that 41% were immigrants (de la Cruz & Brittingham, 2003). In addition, Detroit is home to the largest number of Chaldean Americans (http://chaldeanchamber.com/).

A 2004 in-person survey of 1,016 Arab/Chaldeans within the Detroit metropolitan area found similarities and differences in civic involvement and experience of discrimination by geographic area and religious affilia-tion (Baker & Shryock, 2009), comprising 38% Muslim and 58% Christian (14% Orthodox Christians and 42% Catholics and 2% Protestants) partici-pants. More recent data on ethno-religious composition within the Arab/Chaldean community are not available.

It is possible that the prevalence of binge drinking differs within the larger Arab/Chaldean community by religious affiliation (Holt, Miller, Naimi, & Sui, 2006). Islam has doctrinal prohibition on the manufacturing, transporting, and consumption of alcohol. Chaldeans do not have doctrinal prohibition on alcohol consumption but, unlike Roman Catholic or Orthodox Christians, do not include any alcohol in the Eucharist. Orthodox Christians do not have doctrinal prohibition, but they emphasize modera-tion in their teachings and evaluating the context of drinking to decide if it is approved or discouraged. Thus, these three groups of Muslims, Chaldeans, and Orthodox Christians have different teachings on alcohol use.

In contrast, binge drinking may be present regardless of religious affili-ation. All three groups experience acculturation and discrimination (Awad,

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2010; Baker & Shryock, 2009; Bushman & Bonacci, 2004; Merskin, 2004; Padela & Heisler, 2010; Shaheen, 2001) and, according to research among Latinos and Asian Americans, they may therefore have increased vulnerabil-ity to alcohol abuse (Alegria et al., 2008; Chae et al., 2008; Gee, Delva, & Takeuchi, 2007; Gee, Spencer, Chen, Yip, & Takeuchi, 2007; Gil, Wagner, & Vega, 2000; Takeuchi et al., 2007; Vega & Sribney, 2003). Economic turmoil leading to high levels of unemployment in Michigan, and the United States in general, may further aggravate stress and increase binge drinking. Because the Arab/Chaldean population had a younger age structure than the general population in 2000, the binge drinking rate in this populations may be higher because young adults are more likely to binge drink (Naimi et al., 2003). Self-reported reasons or motivations for adolescents and young adults binge drinking include social reasons, conformity, coping with negative affect, and enhancement of positive effects of alcohol (Patrick, Schulenberg, O’Malley, Johnston, & Bachman, 2011).

The purpose of this study was to explore awareness of the community and the contributory factors protecting or leading to high levels of binge drinking among Arab/Chaldeans, with the goal of recommending culturally appropriate prevention and treatment interventions. To refine interventions and to assess the extent of knowledge about binge drinking, the context of binge drinking was also explored. Because the literature on drinking among Arab/Chaldeans is limited (Abudabbeh & Hamid, 2003; Arfken, Kubiak, & Farrag, 2008; Maalouf & Arfken, 2009) and the state level survey is also lim-ited in what it measures, the qualitative method of focus groups was used (Berg, 2007). The hypothesis was that there would be different contributory factors across different ethno-religious groups within the Arab/Chaldean community.

METHODS

Twelve focus groups with 82 participants total were held between February and July 2011. Inclusion criteria were age between 18 and 29 years (young adults) and self-identification as Arab American or Chaldean American. There were no criteria of knowing or speaking English or of drinking alcohol. Young adults were targeted because this is the age group most likely to binge drink (Naimi, et al., 2003), and it was felt they would be knowledgeable observers of what is happening in their community. Drinking or binge drinking were not inclusion criteria because these activities may be viewed as potentially shameful by religious groups, thus complicating recruitment and group dis-cussion. Focus groups were conducted in both English and Arabic.

Recruitment was purposive to include the three religious groups across different geographic areas in the metropolitan Detroit area. Three focus groups comprised Chaldean Americans (n = 32, 35% men) from two counties

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selected to include a highly affluent neighborhood, allowing exploration of socioeconomic difference. One of these focus groups included new immi-grants and was conducted in Arabic with onsite translation. Two groups comprised Orthodox Christians (n = 21, 53% men) from two counties. Both groups were conducted in English. Seven groups comprised Muslims (n = 48, 44% men) from two distinct geographic areas within one county. One area included Dearborn, the city with the highest concentration of Arab Americans in 2000 (de la Cruz & Brittingham, 2003). All focus groups in Dearborn were conducted in English. The other area included a working class town with large proportion of Yemini, who come from a tradition-orientated country (Nydell, 2006). In this latter area, two male-only and two female-only focus groups were held. One of the female-only focus groups was conducted in English; and the other focus groups were conducted in Arabic. Recruitment for all the focus groups was through links with a social service agency and three faith-based contacts (one Chaldean church serving the affluent neigh-borhood and two Orthodox churches).

Focus groups were conducted in quiet confidential areas. After receiv-ing information sheets in English or Arabic clearly describing the research and the risk and benefits of participation, the participants gave their approval. Each focus group lasted approximately 1 hour and consisted of 2 to 10 par-ticipants. Groups were conducted by a facilitator and assisted by a cofacilita-tor. Discussions were audio recorded digitally. At the conclusion of group discussion, the participants received a $20 gift certificate. All procedures were approved by the Wayne State University’s Institutional Review Board.

A semi-structured interview guide was used to conduct all of the focus groups and was developed cooperatively by the research team. The intro-duction explained the motivation of the study (statewide data on binge drinking) and emphasized that their observations about the community were valued as opposed to learning about their own drinking behavior. Five areas were explored: (1) participants’ awareness of a high level of binge drinking in the community; (2) open-ended discussion of possible reasons; (3) con-text of binge drinking, including who is most likely to binge drink (e.g., age group, gender), what they drink, where they binge drink, and whether they avoid certain areas/people; (4) reactions to proposed reasons from the litera-ture and what other focus groups had said; and (5) awareness and opinion of common prevention strategies to reduce alcohol-related problems, includ-ing prevention messages in the media, use of a designated driver, and an increase on tax of alcoholic beverages (McKnight & Voas, 2004). To maxi-mize anonymity, no individual level data beyond religion and gender were systematically collected.

Data collection and analysis occurred simultaneously using the tech-nique of constant comparative method (Glaser, 1965). All transcripts of the digital recordings were reviewed by the facilitator and cofacilitator and anno-tated with field notes of behavior within days of each focus group. Transcripts

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were then imported into the qualitative software package Atlas.ti (http://www.atlasti.com/) to aid in analysis. Two researchers read the transcripts and independently defined a preliminary coding scheme incorporating the a priori codes from the literature review of immigrant groups and emergent codes. The two researchers then discussed and agreed on a final list of open codes. Emergent codes and contexts of drinking were also checked with subsequent focus groups. At the end of the 12 focus groups, no new codes emerged. Codes that were not confirmed by another focus group of the same ethno-religious groups were excluded. These codes or themes constitute what we refer to as contributory factors and contexts (Table 1 for list of codes and Table 2 for examples). The results were shared and discussed with the research team and with the behavioral health staff from the social service agency to maximize cultural interpretation.

RESULTS

Ten of the 12 focus groups stated that they were not surprised by the state-wide finding of high levels of binge drinking among Arab/Chaldeans. The only two dissenting groups were one composed of newly arrived Chaldeans who were not proficient in English and one composed of two English-speaking Muslim women from the working class area who had never seen or heard of anyone drinking in the community. In contrast, the other Muslim women-only group (Arabic-speaking) from the same area expressed no

TABLE 1 Major Themes

AcculturationArab culture–emergentAvailability–emergentConformityDiscriminationDon’t see it as binge–emergentDrink preferenceDrinking patternDrivingGenderHiddenMedia and role models–emergentParents–emergentPeople want to try–emergentPrevention messages and tax on alcoholReligionResponsibilities (will stop binge drinking when have family and work responsibilities)–

emergentSharing–emergentSocialStress

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TABLE 2 Quotations from Focus Groups Illustrating Themes

Similarities Across All Three Ethno-Religious GroupsAvailablity It’s not hard to get your hands on alcohol whatsoever. You can get it at gas stations. You can go around the block and there is a bar. I go to the drugstores and I see liquor. Every supermarket you will work in will have alcohol in it. Most of us own liquor stores. You can just take a bottle home.Social reason Most Arab and Chaldean people, they don’t drink at home; only when there’s a party or

they go to a bar or something. It’s just something that’s fun. People drink to have fun.Conformity reason They’re just, like, you should drink and come on, have a beer. And I’m, like, I don’t

drink. When it comes to, like, White people, you can simply go like this [waves keys]. No one else will say a word to you the whole night.

If I’m going to do something stupid, I’m not going to do it alone. I’ll try to get people to do it with me.

I mean with Chaldeans, they want to fit in with everyone and do what everyone else is doing.

Enhancement reason How can you have fun without getting drunk? I might as well get drunk and really wasted. You know Whites will drink like a couple of beers but Arabs will drink until they get

drunk.Coping reason Some people have issues or problems and just want to drink and forget about it. They are far away from family and stressed [married men in working class city]. People who have psychological reasons.Role models You watch the guys, the guys on TV, watch people you know go to clubs [and] drinking,

and it’s nothing to them. When you go to school and you see the people you are with drinking, they go to prom [and] they do anything, and they start drinking; it’s OK, it’s not a big deal.

Parents’ influence Personally, I’d rather go to jail for a couple of hours than have my parents know. I can’t imagine calling my dad from jail, my mom from jail, because I got caught

drinking and driving. I’d rather stay in jail than call. They sober up … not because they’re worried about their driving but because they’re

worried about what’s going to happen when they get home.Parents’ facilitating binge drinking One of them told me that they’d go to his basement when his parents were out and his

brothers were out and hang out with his friends because he didn’t have any sisters. They’d go to his basement and drink there.

They’ll have family overseas so that the father and mother travel and the kids stay here at school, and … the house is all theirs, and they … party.

They’re just “Oh no, my child is not doing that. We didn’t raise him like that.”Alcoholic beverage preference Vodka. Arak. The majority of the people I see drinking are drinking liquor, not wine. More like Hessessy or vodka, not like Budweiser.

(Continued)

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Budweiser. Not something expensive. Chaldeans bought more the good liquor, not the cheaper stuff.

Differences Across Three Ethno-Religious GroupsAcculturation It’s all about becoming Americanized [those more acculturated who binge drink]. Arabs who are immigrants. The ones who are born here and grew up with alcohol and

they see it around [those less acculturated who binge drink]. Culture is very strong [no difference by acculturation]. It’s just as our parents are living here longer, more Americanized, I mean, it’s just

becoming more accepted [parents acculturation leads to children binge drinking].Role of gender When it comes to Arabs, the males are the drinkers. (Muslim man) Like my brothers for example can go and do whatever they want; they can come home

whenever they want but we can’t. (Chaldean woman) The same [no gender difference in drinking]. (Orthodox Christian woman)Religious views It’s prohibited in Islam. (Muslim) God made wine to gladden the heart of man. But when you let it alter your state of

mind, that’s when it’s bad. (Orthodox Christian)Hidden If I could add, they don’t really get a chance to doing it as much as the Whites and the

Latinos do it so when they do get that chance, they’ll just take it and drink as much as they can.

They only drink in certain places because they are afraid of other people.Arab Culture Your dad’s neighbor from back home will say “Oh look at his daughter; she had a

drink” or even if you have a Shirley Temple [nonalcoholic mixed drink] and it looks like it’s a drink; you know it brings the possibility of shame.

It’s part of a status symbol for the guys to go out and buy bottles and buy drinks for a girl and get a booth and the more we drink, the drunker we get, so it shows the more money we have.

They won’t want to consume it [if the alcohol tax is increased] … . They like to save and invest. The second cigarette prices went up, they found something else—either stop or smoke less.

TABLE 2 Continued

surprise and could give details about the context of binge drinking including who, where, what alcohol beverage, and contributory factors. All of the other Chaldean, Muslim, and Orthodox Christian groups stated they were not surprised.

Because the aim of this study was to explore contributory factors, with the hypothesis that they may differ by ethno-religious groups, results are grouped by the ethno-religious groups.

Muslims from Working Class City with a Predominately Yemini Population

As stated above, one women-only group was unaware of drinking in the com-munity; this focus group of unmarried women was conducted in English. The

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women supported prevention efforts to reduce alcohol use and mentioned that parents need to talk with their children about alcohol use, similar to how they instruct them about pork. They also wanted to hear prevention information specific to their religion and culture. They were aware of general prevention messages in the media (McKnight & Voas, 2004) and reality television shows with drinking but did not believe it pertained to their culture and religion.

The other women-only focus group was conducted in Arabic with a translator available for the women who did not speak English. The women who spoke English were unaware of drinking in the community. The women who only spoke Arabic were married and stated that drinking does occur in the community among men whose wives and families were in Yemen. They gave great detail about when they drank (after work), where they drank (in their rented houses or a geographically removed park), type of alcohol (beer), and why they drank (stress and lack of other activities besides work). According to them, the men would not drink in front of women or children because that would be disrespectful, but they did congregate in secluded areas to drink. The women were supportive of increasing the tax on alcohol because they viewed the increase in the tax on cigarettes as a contributing factor for why Arab American men’s reduced smoking.

The two men-only groups reported that drinking does occur, especially among the young and Americanized, for social reasons and because it is taboo in their religion. They also mentioned that older men drank; for this demographic group, stress contributed to drinking. They did not directly report that men would avoid drinking in front of women and children but indirectly by emphasizing that drinking was hidden and a shameful act. They also emphasized the easy availability of alcohol, especially at gas stations. The men who worked at the gas stations did not mention any religious con-flict with selling alcohol. For the men who were still in school, they empha-sized how it is hidden from families and general community but that at school it is more open. Some of the male students who drink are well-respected. One young man told of confronting a classmate who drank and demanding to know why he was going against his religion and culture. The response was: “life is short and enjoy it.”

Muslims from Dearborn

The first focus group in this geographic area mostly comprised college stu-dents. They were not surprised by the statistics and gave many detailed accounts of excessive drinking among the Arab American community. They attributed the drinking behavior to the youth who wanted to have fun together, enormous peer pressure (more so than with other racial/ethnic groups), and lack of responsibility. They emphasized the different gender roles and the importance of maintaining family honor, especially for girls. However, they also pointed out that some girls sneak out and some families

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were lenient. Excessive drinking started in high school and would continue until the person married. They reported vodka as the drink of choice, and the drinking places of choice were selected to lower the likelihood of being seen by older members of the community. Care was also taken to avoid being stopped by the police because they would call their parents. Above all, they wanted to avoid their parents hearing about drinking. They saw exces-sive drinking as increasingly important to the youth. In their opinion, increased taxes would not change the quantity consumed, although people mentioned cheaper brands of vodka and more pre-gaming (i.e., drinking prior to going out) as options to decrease costs. They pointed out that the increase in cigarette taxes did not change smoking behavior at all among Arab Americans.

The second focus group included some young unmarried adults and married young adults with jobs. The participants repeated themes from the other focus group of peer pressure, early excessive drinking, and shame. However, they had a more compassionate view of older men drinking. They pointed out that the men might have experienced economic problems through no fault of their own and turn to alcohol, which, they emphasized, did not make them bad men. It was also notable that the married and employed members of the group were not able to give details about binge drinking in the community. From their responses, it appears that excessive drinking is well known to occur among the youth and possibly others, but they had not seen it occur.

In the third focus group, the women emphasized the double standard regarding drinking in the community (tolerated for men as long as they do not get caught but prohibited for women), vodka as the alcohol of choice, an episodic drinking pattern, a young age of initiation, and intense peer pressure. They told personal stories of classmates who drank and riding with them in cars only to find out that alcohol was being transported. For them, it was imperative to get out of the car immediately due to the possibility of being in an accident, having their picture taken in the car with the alcohol, and their parents finding out about it. They also mentioned peers who had to quit working at drug stores because alcohol was sold there.

Chaldeans

There were three focus groups composed of Chaldeans. The first focus group comprised predominately men and was conducted in English. The partici-pants wanted to know the definition of binge drinking. Only after hearing the research-based definition did they agree that it occurred in their com-munity. They stressed that drinking was celebratory, with Hennessy, and always with a group of family and friends. One participant contrasted the pattern of buying drinks among her Chaldean friends with the pattern among her White friends. According to her description, among Chaldeans it is

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important to share and be generous. Thus, they take turns buying rounds of shots or drinks. Among her White friends, each person is responsible for ordering and paying separately. The Chaldean pattern of buying drinking was verified with the other Chaldean focus groups. The first focus group said the double standard of disapproving of women drinking was only applied to older women, not to young women. They were aware of prevention mes-sages but did not believe that a tax increase would affect drinking. They said Chaldeans are proud and prefer quality alcoholic beverages, regardless of the price.

The second focus group was also conducted in the same geographic area but with a group of recent arrivals. This focus group was conducted in English with an Arabic translator present. The focus group was surprised by the statistic and the definition of binge drinking. They immediately men-tioned people with psychological problems as binge drinkers. The double standard of drinking by gender was endorsed. They did not know the legal age of drinking and were not familiar with any prevention messages.

The third focus group of Chaldeans was held in a geographic affluent area. For this focus group, both women and men promised to attend but only the women showed up. The women were either second-generation immigrants or had immigrated at early age. They were articulate about the differences between White and Chaldean culture in general and specifically drinking. They emphasized the double standard of drinking regardless of age and the need for Chaldean women to maintain the honor of the family and avoid bringing shame to it. Women avoided drinking where they would be observed by older members of the Chaldean community. All participants believed that drinking and binge drinking were increasingly occurring in the community. They were proud that their men could drink more than White men. They saw drinking as celebratory and as a way to have fun with family and friends and as a way to show status. Men bought bottles of alcohol to share with male and female friends. Taxis and limousines were used after partying. They were aware of public prevention messages and did not believe that a tax increase on alcohol would have any effect on drinking in their community.

Orthodox Christians

Two focus groups were composed of Orthodox Christians. From their com-ments, it was determined that they were well educated, born in the United States, and had traveled to the Middle East. The first group was a short focus group as they said binge drinking occurred at parties with family and friends, without a double standard. There was no avoidance of people or places. They did not see any difference by generation or where people were born or between drinking behaviors in the local Arab American community com-pared with their relatives in Syria, Lebanon, and other countries. They had

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heard of prevention messages and took specific steps to have a designated driver for their group when out drinking. Drinking was viewed as part of the celebration of life to be shared across age groups. They did not view drink-ing alcohol as shameful but rather as part of life. Moderation, for them, was the key. The specific drink, arak, was identified as consumed but also other alcoholic beverages. Excessive drinking was frowned on and was thought to bring shame to the family and community, but they defined excessive drink-ing by functional impairment and not by the number of drinks consumed in a single setting.

The second focus group of Orthodox Christians echoed the themes of episodic celebration with family and friends, arak as beverage of choice, and lack of double standard. The participants also confirmed that an arrest for drunk driving would bring shame to the family. One participant stressed that her drinking and driving was more influenced by avoiding bringing shame to her parents than any prevention message. The focus group concluded with a brief summary of the Orthodox Christian doctrinal view on alcohol—that drinking per se is not prohibited but that the context and consequences determine whether the drinking is viewed positively or negatively.

DISCUSSION

The high level of binge drinking among the Arab/Chaldean population, especially among those who drink, found in general population surveys was not a surprise to most of the young adults participating in the focus groups. Furthermore, many believed that the rate would continue to increase. Social reasons predominated and were consistently reported across all three ethno-religious groups sampled. Other factors consistently reported across groups were the easy availability of alcohol in the environment, importance of par-ents in discouraging risky behavior or alternatively facilitating binge drinking, and conformity to the behavior of the group. According to the participants, Arab/Chaldeans binge drink to have fun with family and friends, to share in the activity, and to be part of the group.

The important role of parents and family was best illustrated by the comments made by several young participants across ethno-religious groups that they would rather go to jail then have their parents know they were drinking (Muslims) or driving after drinking (Chaldeans and Orthodox Christians). Thus the strong influence of parents even among participants who were employed, had families, and almost 30 years old suggests preven-tion and treatment interventions should leverage this influence and include parents and families in their activities. Of course, there were reports of par-ents enabling the binge drinking by not monitoring activities. In Arab coun-tries, boys are traditionally allowed great deal of freedom but they live in an environment where they are continually observed or monitored by the entire

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community. Thus, there needs to be education of immigrant parents that less community monitoring occurs in the United States, especially when the children have the possibility of traveling to other communities to drink. Overall, the role of parents to be responsible and provide for the family was stressed in all focus groups, even among the older participants. Thus, drinking was uni-versally viewed negatively if it interfered with that primary role. Children, even as grown adults with jobs, were still responsible to their parents.

Consistent with our hypothesis, the contributory factors of context for drinking and gender roles differed by ethno-religious groups. In the focus groups with Muslims from Dearborn, drinking was hidden from the parents and older members of the community by travel to other communities. Both men and women drank, but it was more shameful for the family of the women if they were seen drinking. For the Muslims from the working class city, drinking was hidden from all except others who drank and was exclu-sively reported among men. There was no description of the social aspect of drinking or details on sharing. This area may have preserved the more con-servative view of gender roles and alcohol use from Yemen. It was the only location where women wore face-covering niqabs and gender-segregated focus groups occurred. For the Chaldeans, women hid their drinking from older members of the community, but men did not hide their drinking. For both genders, drinking occurred in public settings, with an emphasis on sharing with friends and family. The public sharing could also be used to indicate status, as reported by the more affluent Chaldean focus group. This group also had the financial means to use taxis and limousines instead of designated drivers. For the Orthodox Christians, there was no gender differ-ence in drinking.

The effect of a tax increase on alcohol differed across the focus groups but not by religious groups. Instead, the effect was uniformly viewed as minimal among participants from middle class or affluent neighborhoods and uniformly viewed as positive among participants from working class neighborhoods. Interestingly, all the focus groups (except the one with new arrivals) compared a hypothetical tax increase on alcohol with a recent tax increase on cigarettes. Participants from the working class neighborhoods reported that Arab Americans stopped or reduced smoking after the tax increase; participants from the middle class or affluent neighborhoods reported that Arab/Chaldeans continued to smoke after the tax increase. Quantitative studies are needed to address this issue.

Acculturation (or being Americanized) was recognized by the focus group participants as occurring. However, its relationship with binge drink-ing was not consistently reported, even within ethno-religious groups. Some participants viewed Arab/Chaldeans born in the United States as more likely to binge drink, whereas others viewed them as less likely to drink. Obviously, quantitative studies are needed to address the importance of acculturation to binge drinking among Arab/Chaldeans.

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The participants acknowledged that people with psychological problems would binge drink. This was the first reason advanced by the recent Chaldean arrivals from Iraq for the high rate of binge drinking. Other participants allowed that some people may binge drink due to psychological problems, but it was not viewed as a major contributor to the high level of binge drinking among Arab/Chaldeans in Michigan. Regardless of its prevalence as a contributory factor, mental illness and trauma should not be ignored in treatment, whether for Arab/Chaldeans or for other racial/ethnic groups (Drake et al., 2001).

The participants were open and articulate about binge drinking. Some of them were surprised by the low number of drinks to qualify for binge drinking, whereas others were quick to note that they hear about binge drinking but that they do not drink. Thus, there is the possibility that the statewide prevalence of binge drinking among Arab/Chaldeans is influenced by reporting bias. On one hand, Arab/Chaldeans may be reporting their con-sumption more honestly than other groups because they do not know that their consumption qualifies as binge drinking. Alternatively, due to the shame surrounding drinking for some Arab/Chaldeans they may deny any alcohol use in the prior month. Both biases may occur but cannot be determined through focus groups.

The study is limited in its conclusions by the research method used (i.e., focus groups). The participants were not randomly selected from the geo-graphic area, and discussion may have been influenced by presence or state-ments from other participants. The facilitators were trained and took steps to minimize pressure but people may have been influenced by the presence of others. Although focus groups can be used to explore awareness of binge drinking in the Arab/Chaldean community and suggested contributory factors that can be used to tailor prevention and treatment interventions, they cannot be used to determine prevalence or to test associations. The study was also limited in that it was not exhaustive of all ethno-religious groups within the larger Arab/Chaldean community (Baker & Shryock, 2009). Importantly, Catholics besides Chaldeans were not included in the sampling frame.

In conclusion, the high rate of binge drinking among Arab/Chaldeans in Michigan was not surprising to focus groups composed of different ethno-reli-gious groups within the larger community. Contributory factors to binge drink-ing identified showed more similarities than differences across different groups. These findings can be used to tailor prevention and treatment interventions.

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binge drinking among arab/chaldeans: an exploratory study

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