Alcohol and public health in Africa: can we prevent alcohol-related harm from increasing?

Setting the scene: a scoping review of gambling research in Ghana

Ghana, like many other African countries, has seen a rapid expansion in gambling industry activity in the last decade with sports betting becoming a popular pastime among young Ghanaian males. The proliferation of land based, and online gambling operations presents a significant public health threat to the citizenry. Yet little is known about gambling participation and harms, the size of the gambling market and the role of the gambling industry in influencing and perpetuating gambling behaviour in Ghana. The aim of this study was to contribute to understanding the extent of gambling research in Ghana by mapping out what the current literature indicates. Six databases were searched for peer-reviewed journal articles that focused on gambling in Ghana. The findings from this review demonstrate gambling research in Ghana is in a nascent state with a predominant focus on individual factors and limited consideration of public health. The implications for future research are highlighted, including the requirement for a nationally representative study to understand the prevalence of gambling participation and harm, and the role of the gambling industry. Public health action grounded in sound evidence is urgently required to address the individual and community level problems associated with this harmful commodity.

Prevalence and correlates of alcohol use and risky drinking among undergraduate students in Johannesburg, South Africa: a cross-sectional study

BACKGROUND

Alcohol use and risky drinking are significant public health problem globally. Young people, including university students, are among the most affected populations. We conducted the study to determine the prevalence and correlates of alcohol use and risky drinking among undergraduate students in the Faculty of Health Sciences at the University of the Witwatersrand, South Africa.

METHODS

We conducted a cross-sectional study using an anonymous, self-administered online survey in REDCap. The survey questionnaire consisted of socio demographic, and alcohol use questions using the risky drinking identification screening tool (AUDIT-C). We performed descriptive statistics, bivariate and multivariable logistic regression to determine factors associated with alcohol use and risky drinking. The p-value of < 0.05 was considered statistically significant.

RESULTS

The response rate was 15.7%. Most participants were female (69.6%) and majority of the participants were White (38.1%). The prevalence of lifetime use of alcohol was 79.1%, and among the lifetime users; 70.2% reported alcohol use in the last 12-months, 37.1% reported alcohol use in the last 30 days. The prevalence of risky drinking was 54.8% among lifetime drinkers. Factors significantly associated with current alcohol use were siblings alcohol use (aOR = 1.79, 95% CI: 1.02-3.15) and parents alcohol use (aOR = 2.58, 95% CI: 1.39-4.80), white race (aOR = 5.70, 95% CI: 3.12-10.41), and always or daily exposure to alcohol marketing in the media (aOR = 3.31, 95% CI: 1.07-10.24). Factors associated with risky drinking were: Indian/Asian race (aOR = 2.82, 95% CI: 1.09-7.31), White race (aOR = 2.15, 95% CI: 1.14-4.04), and exposure to alcohol marketing in the media as follows, most of the time (aOR = 3.42, 95% CI: 1.29-9.04) and Always/daily exposure (aOR = 3.31, 95% CI: 1.07-10.24).

CONCLUSION

The reported alcohol use and risky drinking were common amongst undergraduate students at Wits university. There is an urgent need to design, pilot and adapt targeted interventions for this population group.

Current alcohol, tobacco, and khat use and associated factors among adults living in Harari regional state, eastern Ethiopia: A community-based cross-sectional study

Background

Psychoactive substance use becomes a major public health and socioeconomic problem worldwide. Despite its burden and consequences, there is no community-based study conducted on psychoactive substance use and associated factors in eastern Ethiopia. Therefore, this study aimed to assess the magnitude and determinants of current alcohol, tobacco, and khat among adults living in Harari regional state, eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted on 955 adults living in Harari regional state. Participants were randomly recruited using a simple random sampling technique. Data were collected by interviewer-administered structured and semi-structured questionnaires. Data were entered into Epi Data version 3.1 and exported to Stata version 14.0 for analysis. Logistic regression analysis was performed to determine the association between the outcome and independent variables, and the statistical significance was declared at a p < 0.5.

Results

Of 955 eligible participants, 95.29% participated in the study. The overall prevalence of current alcohol use, tobacco use, and khat use in this study was 8.24, 14.5, and 63.30%, respectively. The availability of alcohol, being unemployed, and being a current khat user were significantly associated with current alcohol use. Being male, having a low level of education, having peer pressure, having a common mental disorder, being a current alcohol user, and being a khat user were identified as significant predictors for current tobacco use. The age between 31 and 40 years, being a Muslim religion follower, being a farmer, being a current tobacco user, and availability of khat were significantly associated with current khat use.

Conclusion and recommendations

The prevalence of psychoactive substance use in the study area was relatively high compared with that of previous studies. By considering these determinants, screening, early identification, and developing appropriate intervention strategies to prevent and tackle current alcohol, tobacco, and khat use in the community should be of great concern.

Preventing Alcohol-Related Harm in East Africa: Stakeholder Perceptions of Readiness across Five Countries

OBJECTIVE

While alcohol-related harm is a recognized public health priority, the capacity to address and mitigate its harm is lacking, primarily in low-income countries. Recent developments including new tools that can assess readiness for preventing alcohol-related harm, specifically in low-resource settings, can be used to determine strengths and opportunities for supporting, planning, and resource allocation. In this study, we determined the perceptions of readiness and capacity for the prevention of alcohol-related harm across East Africa among stakeholders engaged in such work.

METHODS

We conducted a cross-sectional survey in 2020, distributed by the East Africa Alcohol Policy Alliance to their member alliances and stakeholders across five countries in East Africa (i.e., Burundi, Kenya, Rwanda, Tanzania, and Uganda). The survey included modified measures from the Readiness Assessment for the Prevention of Child Maltreatment (RAP-CM) short form, organizational size and funding, research capacity and priorities, and perceptions related to alcohol prevention and harm both locally and in the region. Analyses were computed based on 142 persons/organizations completing the survey.

RESULTS

In terms of general readiness, the overall adjusted aggregate score for East Africa was 39.70% (ranging from 30.5% in Burundi to 47.0% in Kenya). Of the 10 domains assessed (on a 0-10 scale), across all countries, knowledge of alcohol prevention (8.43), institutional links and resources (6.15) and legislation, mandates and policies (5.46) received the highest scores. In contrast, measures pertaining to resources (i.e., material, human, technical, and informal) received the lowest score.

CONCLUSIONS

Our results demonstrate substantial variability in the readiness to address alcohol-related harm across East Africa. The highest capacity was noted for knowledge towards alcohol prevention, institutional links, and legislative mandates and policies. However, important gaps were noted in terms of attitudes towards alcohol prevention, the will to address the problem, as well as material, human, and informal resources, which need to be urgently addressed to strengthen capacity for addressing and mitigating the significant toll of alcohol-related harm in the region.

A readiness assessment for the prevention of alcohol-related harm in West Africa: A new methodological approach to inform practice and policy

OBJECTIVE

Alcohol-related harm is a growing concern globally and particularly in West Africa. However, tools for assessing the readiness for prevention of alcohol-related harm in low-resource settings have been lacking. We modified the WHO tool, the Readiness Assessment for the Prevention of Child Maltreatment Short Form (RAP-CM), to assess readiness for the prevention of alcohol-related harm across West Africa.

METHODS

We conducted a cross-sectional survey in the fall of 2020, distributed by the West Africa Alcohol Policy Alliance to their member alliances and stakeholders, predominantly community-based organizations (CBOs) and non-governmental organizations (NGOs), across 7 countries in West Africa (N = 140). The survey included modified measures from the RAP-CM short form.

RESULTS

In terms of general readiness, the overall adjusted aggregate score for West Africa was 45.0% (ranging from 42.9% in Liberia to 52.7% in Senegal). Of the ten domains assessed (on a 0-10 scale), across all countries, knowledge of alcohol-related harm prevention (8.3) and legislation, mandates, and policies (6.7) received the highest readiness scores. The lowest readiness scores were observed for human and technical resources (2.5), attitudes toward preventing alcohol-related harm (2.7), and the will to address the problem (2.9).

CONCLUSIONS

Our results demonstrate substantial variability across domains in the readiness to address alcohol-related harm with clear strengths and limitations for future priority setting and capacity building. The barriers to progress include attitudes toward alcohol-related harm prevention, lack of willingness to address the problem, and limited human and technical resources available. These barriers need to be mitigated to address the high burden of alcohol-related harm in the region and to inform both practice and policy.

PRACT: a pragmatic randomized adaptive clinical trial protocol to investigate a culturally adapted brief negotiational intervention for alcohol use in the emergency department in Tanzania

BACKGROUND

Alcohol use in resource-limited settings results in significant morbidity and mortality. These settings lack the necessary specialty-trained personnel and infrastructure. Therefore, implementing evidence-based interventions from high-income settings, like a brief negotiational intervention (BNI) for alcohol, will require rapid production of evidence of effectiveness to guide implementation priorities. Thus, this study describes a clinical trial protocol to rapidly optimize and evaluate the impact of a culturally adapted BNI to reduce alcohol-related harms and alcohol consumption among injury patients.

METHODS

Our pragmatic, adaptive, randomized controlled trial (PRACT) is designed to determine the most effective intervention approach to reduce hazardous alcohol use among adult (≥18 years old) in acute (< 24 h) injury patients. Our culturally adapted, nurse-delivered, intervention (PPKAY) has been augmented with evidence-based, culturally appropriate standards and will be evaluated as follows. Stage 1 of the trial will determine if PPKAY, either with a standard short-message-service (SMS) booster or with a personalized SMS booster is more effective than usual care (UC). While optimizing statistical efficiency, Stage 2 drops the UC arm to compare the PPKAY with a standard SMS booster to PPKAY with a personalized SMS booster. Finally, in Stage 3, the more effective arm in Stage 2 is compared to PPKAY without an SMS booster. The study population is acute injury patients who present to Kilimanjaro Christian Medical Centre, Tanzania, who (1) test alcohol positive by breathalyzer upon arrival; (2) have an Alcohol Use Disorder Identification Test of 8 or above; and/or (3) have reported drinking alcohol prior to their injury. Outcome measures will be evaluated for all arms at 3, 6, 9, 12, and 24 months. The primary outcome for the study is the reduction of the number of binge drinking days in the 4 weeks prior to follow-up. Secondary outcomes include alcohol-related consequences, measured by the Drinker Inventory of Consequences.

DISCUSSION

The findings from this study will be critically important to identify alcohol harm reduction strategies where alcohol research and interventions are scarce. Our innovative and adaptive trial design can transform behavior change research and identify the most effective nurse-driven intervention to be targeted for integration into standard care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04535011 . Registered on September 1, 2020.

Youths' Perceptions Of The Relation Between Alcohol Consumption And Risky Sexual Behaviour in the Western Cape, South Africa: A Qualitative Study

The purpose of this study is to explore the factors that youth identify as contributing to alcohol consumption, and more specifically its relation to risky sexual behaviour among youth. We employed an exploratory qualitative method using focus group discussions with 34 young people between the ages of 18-25-years-old in low socio-economic status communities in the Western Cape province of South Africa. Data were analyzed thematically utilizing Braun and Clarke's (2006) six-step thematic analysis process. We identified two thematic domains pertaining to alcohol consumption and risky sexual behaviour, namely individual and social factors, each comprising three themes. The individual factors thematic domain comprises intrapersonal influences, employment and educational attainment; while the social factors thematic domain includes interpersonal influences, social influences, and hope for the future. Youth living in low socio-economic status communities were thought to be at greater risk of alcohol misuse and subsequent risky behaviour, given the political and social history of marginalisation, systematic oppression, and social inequality. To address alcohol use and risky sexual behavior among youth, we recommend interventions with adolescents, parents or guardians, and the community. More specifically, interventions aimed at adolescents should focus on the transition to young adulthood. Interventions with parents should focus on their role in modelling and potentially regulating alcohol consumption. Finally, community interventions should centre on drinking behaviors, levels of drinking, what constitutes harmful drinking, and how to identify when treatment and recovery support is likely to be required.

Alcohol use during pregnancy in rural Lesotho: "There is nothing else except alcohol"

OBJECTIVE

Reducing alcohol use during pregnancy is a pressing public health priority in Sub-Saharan Africa, but insight into the factors that influence prenatal drinking practices is lacking. This study investigated perceptions of, and motivations for, alcohol consumption during pregnancy and associated practices in a rural district of Lesotho.

METHODS

A combination of purposive and snowball sampling methods were used to identify pregnant women and mothers with young children from the general community, as well as from alcohol-serving venues. Between September 2016 and March 2017, a trained data collector conducted in-depth interviews with 40 women on reasons why pregnant women drink, what they know about the risk of drinking alcohol during pregnancy, and perceptions of women who drink during pregnancy.

RESULTS

Sixty-five percent of women (n = 26) reported that they consumed alcohol during pregnancy. Findings were clustered into four themes: 1) alcohol use in daily and cultural life; 2) alcohol as relief from stress and hunger; 3) alcohol's effect on the baby; and 4) access to information about alcohol consumption. Our data suggest that alcohol use was a prominent feature of daily life and a key part of traditional events and ceremonies. Other than potentially harming the baby through falling on their stomachs while inebriated, women did not mention other risks associated with prenatal alcohol use. Rather, there were prominent beliefs that drinking alcohol - home-brewed alcohol in particular - had cleansing or protective benefits for the baby. Experiences of food insecurity were prominent, and women reported that alcohol helped curb their hunger and allowed them to save food to give to their children.

CONCLUSIONS

Within this context of chronic poverty and food insecurity, alcohol use during pregnancy will continue to represent a valid, though tragic choice if the structural conditions and current social arrangements that facilitate prenatal alcohol use remain unchanged.

Adolescent alcohol consumption: protocol for a scoping review of screening and assessment tools used in Africa

BACKGROUND

Alcohol consumption is a key public health challenge in sub-Saharan Africa, which has the highest burden of alcohol attributable injury and disease of any region. Excess alcohol use is particularly harmful for adolescents and has been associated with neurocognitive defects and social and emotional problems. Effective screening and assessment tools are necessary to implement, evaluate and monitor interventions to prevent and decrease adolescent alcohol use. Most of these tools have been used among adolescent groups in high income settings; data on their effectiveness in Africa, where much alcohol use is unregulated, is limited. This scoping review will examine and map the range of tools in use and create an evidence base for future research in adolescent alcohol prevention and control in Africa.

METHODS

The review will include all relevant study designs and grey literature. Inclusion and exclusion criteria have been designed using the Population - Concept - Context framework, and two reviewers will independently screen titles, abstracts and then full text to determine eligibility of articles. The Cochrane Library, MEDLINE, CINAHL and Global Health data bases will be searched for peer reviewed publications. The search strategy for grey literature will include Google searches and searches in websites of pertinent professional bodies and charities. The methodological framework proposed by Arksey and O'Malley and adaptations by the Joanna Briggs Institute and Levac et al. will be used. An iterative approach to charting, collating, summarising and reporting the data will be taken, with the development of charting forms and the final presentation of results led by the extracted data.

RESULTS

This scoping review protocol describes a secondary analysis of data already collected to explore and map alcohol consumption measurement tools in adolescents in Africa.

CONCLUSIONS

It is anticipated that our findings will provide an evidence base surrounding tools used to measure adolescent alcohol consumption in Africa. These findings are likely to be useful in informing future research, policy and public health strategies. Findings will be disseminated widely through peer-reviewed publication and in various media, for example, conferences, congresses or symposia.

SYSTEMATIC REVIEW REGISTRATION

Scoping Review Registration: Open Science Framework ( https://osf.io/bjhgw/ ).

Foreign investment in emerging legal medicinal cannabis markets: the Jamaica case study

INTRODUCTION

The establishment of a legal market for medicinal cannabis under the Dangerous Drugs Amendment Act 2015 has positioned Jamaica at the forefront of cannabis law reform in the developing world. Many local cannabis businesses have attracted investment from overseas, including from Canada, US and Europe.

AIM

To explore the opportunities and risks of foreign investment in an emerging domestic legal cannabis market in a developing country.

METHODS

Thematic analysis of semi-structured face-to-face interviews with 22 key informants (KIs) from the Jamaican government, local cannabis industry, academia and civil society, and field observations of legal and illegal cannabis cultivators.

RESULTS

KIs from the Jamaican public agencies and domestic cannabis entrepreneurs saw foreign investment as an essential source of capital to finance the start-up costs of legal cannabis businesses. Local cannabis entrepreneurs prioritised investors with the greatest financial resources, brand reputation and export networks. They also considered how allied an investor was with their business vision (e.g., organic cultivation, medical vs. recreational). The key benefits of partnering with a foreign investor included transfer of technical knowledge and financial capital, which enhanced production, quality assurance and seed-to-sale tracking. Some KIs expressed concern over investors' focus on increasing production efficiency and scale at the expense of funding research and development (R&D) and clinical trials. KIs from the local industry, government agencies and civil society highlighted the risks of 'predatory' shareholder agreements and domestic political interference. Concerns were raised about the impact of foreign investment on the diversity of the domestic cannabis sector in Jamaica, including the commitment to transition traditional illegal small-scale cannabis cultivators to the legal sector.

CONCLUSION

While foreign investment has facilitated the commercialisation of the cannabis sector in Jamaica, regulatory measures are also needed to protect the domestic industry and support the transition of small-scale illegal cultivators to the legal regime. Foreign investments may alter the economic, social and political determinants of health in transitioning from illegal to legal cannabis market economy.

Advancing public health policy making through research on the political strategies of alcohol industry actors

Development and implementation of evidence-based policies is needed in order to ameliorate the rising toll of non-communicable diseases (NCDs). Alcohol is a key cause of the mortality burden and alcohol policies are under-developed. This is due in part to the global influence of the alcohol industry. We propose that a better understanding of the methods and the effectiveness of alcohol industry influence on public health policies will support efforts to combat such influence, and advance global health. Many of the issues on the research agenda we propose will inform, and be informed by, research into the political influence of other commercial actors.

Public Health Surveillance Studies of Alcohol Industry Market and Political Strategies: A Systematic Review

OBJECTIVE

This review examines public health surveillance (PHS) studies of alcohol industry actors that explore the implications of the integration of business and political strategies for public health.

METHOD

Eligible for inclusion were studies published in English language peer-reviewed journals since 1980 that sought to investigate both alcohol industry business and political strategies and their implications for public health. Studies were also required to present economic, political, and health data together. Seven databases were searched until May 2018.

RESULTS

Six studies were identified as eligible for inclusion in this review, undertaken in high-, middle-, and low-income countries and published between 2000 and 2015. Political strategies are driven largely by business interests, whether at the company, sectoral, or industry level, and corporate social responsibility activities may be integrated within overall strategies. There is a high degree of collaboration in political strategy development between companies, facilitated by growing concentration among global producers operating in increasingly oligopolistic markets. There are limited insights into the dynamics of market competition and limited methodological data available.

CONCLUSIONS

PHS studies play a valuable role in identifying aspects of alcohol industry strategies that warrant more detailed and carefully designed research, as well as in elucidating global health implications. Further research in PHS and other kinds of studies will assist efforts to reduce the global burden of disease caused by alcohol.

Pathways between urbanization and harmful substance use

PURPOSE OF REVIEW

Epidemiological literature suggests that urbanization is potentially linked to a number of stressors that could be associated with harmful substance use and mental disorders. This may vary by country. This review gives attention to emergent literature examining the pathways between urbanization and harmful substance use.

RECENT FINDINGS

Studies examining the links between urbanization, mental health and substance use suggest complex pathways between urbanization and substance use as well as a range of modifying variables that could contribute to these associations. Such variables include increased supply of illicit and licit substances brought about by economic development, globalization and technology as well as an increased demand for particular substances. Rural areas may also have unique factors associated with harmful substance use but these are beyond the scope of this review.

SUMMARY

We have presented evidence to suggest potential associations between urbanization and harmful substance use. We acknowledge that data are limited because of a paucity of longitudinal studies elucidating these relationships.

Alcohol and Tobacco Use among Men in Zambia and Zimbabwe

Background

To date, there is no country-representative study on tobacco and alcohol use in Zambia and Zimbabwe despite the fact that these two countries rank among the top producers of tobacco worldwide. To fill this research gap, we conducted this study to measure the prevalence of tobacco and alcohol consumption among adolescent and adult men in Zambia and Zimbabwe. Special attention was given to the age differential in the prevalence of smoking and drinking.

Methods

Country-representative data on alcohol and tobacco use along with relevant sociodemographic parameters were collected from Demographic and Health Surveys. Sample population were 23,169 men (14,773 from Zambia and 8,396 from Zimbabwe) aged 15-54 years. Data were analysed using multivariate regression techniques.

Results

Prevalence of tobacco use was 19.9% (19.0-20.9) in Zambia and 18.4% (17.4-19.5) in Zimbabwe, and that of alcohol was 37.6% (36.4-38.9) in Zambia and 50.5 (48.9-52.1) in Zimbabwe. In both of the countries, the majority of the tobacco and alcohol users were aged between 24-39 years. Results of multivariate regression analysis showed a significant positive association between tobacco and alcohol use with age, place of residence, religious affiliation, marital status, education and wealth quintile.

Conclusion

Nearly one-fifth of all men in the age group of 15-54 years smoke tobacco in Zambia and Zimbabwe, with the prevalence being most pronounced among those aged between 25-39 years. The predominantly young age structure of alcohol and tobacco users warrant demographically tailored anti-tobacco and alcohol controlling programmes.

Prevalence and determinants of heavy episodic drinking among adults in Kenya: analysis of the STEPwise survey, 2015

BACKGROUND

Globally, alcohol consumption contributes to 3.3 million deaths and 5.1% of Disability Adjusted Life Years (DALYs), and its use is linked with more than 200 disease and injury conditions. Our study assessed the frequency and patterns of Heavy Episodic Drinking (HED) in Kenya. HED is defined as consumption of 60 or more grams of pure alcohol (6+ standard drinks in most countries) on at least one single occasion per month. Understanding the burden and patterns of heavy episodic drinking will be helpful to inform strategies that would curb the problem in Kenya.

METHODS

Using the WHO STEPwise approach to surveillance (STEPS) tool, a nationally representative household survey of 4203 adults aged 18-69 years was conducted in Kenya between April and June 2015. We used logistic regression analysis to assess factors associated with HED among both current and former alcohol drinkers. We included the following socio-demographic variables: age, sex, and marital status, level of education, socio-economic status, residence, and tobacco as an interaction factor.

RESULTS

The prevalence of HED was 12.6%. Men were more likely to engage in HED than women (unadjusted OR 9.9 95%, CI 5.5-18.8). The highest proportion of HED was reported in the 18-29-year age group (35.5%). Those currently married/ cohabiting had the highest prevalence of HED (60%). Respondents who were separated had three times higher odds of HED compared to married counterparts (OR 2.7, 95% CI 1.3-5.7). Approximately 16.0% of respondents reported cessation of alcohol use due to health reasons. Nearly two thirds reported drinking home-brewed beers or wines. Tobacco consumption was associated with higher odds of HED (unadjusted OR 6.9, 95% CI 4.4-10.8); those that smoke (34.4%) were more likely to engage in HED compared to their non-smoking counterparts.

CONCLUSION

Our findings highlight a significant prevalence of HED among alcohol drinkers in Kenya. Young males, those with less education, married people, and tobacco users were more likely to report heavy alcohol use, with male sex as the primary driving factor. These findings are novel to the country and region; they provide guidance to target alcohol control interventions for different groups in Kenya.

Drinking patterns vary by gender, age and country-level income: Cross-country analysis of the International Alcohol Control Study

INTRODUCTION AND AIMS

Gender and age patterns of drinking are important in guiding country responses to harmful use of alcohol. This study undertook cross-country analysis of drinking across gender, age groups in some high-and middle-income countries.

DESIGN AND METHODS

Surveys of drinkers were conducted in Australia, England, Scotland, New Zealand, St Kitts and Nevis (high-income), Thailand, South Africa, Mongolia and Vietnam (middle-income) as part of the International Alcohol Control Study. Drinking pattern measures were high-frequency, heavier-typical quantity and higher-risk drinking. Differences in the drinking patterns across age and gender groups were calculated. Logistic regression models were applied including a measure of country-level income.

RESULTS

Percentages of high-frequency, heavier-typical quantity and higher-risk drinking were greater among men than in women in all countries. Older age was associated with drinking more frequently but smaller typical quantities especially in high-income countries. Middle-income countries overall showed less frequent but heavier typical quantities; however, the lower frequencies meant the percentages of higher risk drinkers were lower overall compared with high-income countries (with the exception of South Africa).

DISCUSSION AND CONCLUSIONS

High-frequency drinking was greater in high-income countries, particularly in older age groups. Middle-income countries overall showed less frequent drinking but heavier typical quantities. As alcohol use becomes more normalised as a result of the expansion of commercial alcohol it is likely frequency of drinking will increase with a likelihood of greater numbers drinking at higher risk levels.

Cross-country comparison of proportion of alcohol consumed in harmful drinking occasions using the International Alcohol Control Study

INTRODUCTION AND AIMS

This study examines the proportion of alcohol markets consumed in harmful drinking occasions in a range of high-, middle-income countries and assesses the implications of these findings for conflict of interest between alcohol producers and public health and the appropriate role of the alcohol industry in alcohol policy space.

DESIGN AND METHODS

Cross-sectional surveys were conducted in 10 countries as part of the International Alcohol Control study. Alcohol consumption was measured using location- and beverage-specific measures. A level of consumption defined as harmful use of alcohol was chosen and the proportion of the total market consumed in these drinking occasions was calculated for both commercial and informal alcohol.

RESULTS

In all countries, sizeable proportions of the alcohol market were consumed during harmful drinking occasions. In general, a higher proportion of alcohol was consumed in harmful drinking occasions by respondents in the middle-income countries than respondents in the high-income countries. The proportion of informal alcohol consumed in harmful drinking occasions was lower than commercial alcohol.

DISCUSSION AND CONCLUSIONS

Informal alcohol is less likely to be consumed in harmful drinking occasions compared with commercial alcohol. The proportion of commercial alcohol consumed in harmful drinking occasions in a range of alcohol markets shows the reliance of the transnational alcohol corporations on harmful alcohol use. This reliance underpins industry lobbying against effective policy and support for ineffective approaches. The conflict of interest between the alcohol industry and public health requires their exclusion from the alcohol policy space.

Substance Use and HIV Risk Among Men Who Have Sex With Men in Africa: A Systematic Review

BACKGROUND

Substance use and its relation to HIV risk among men who have sex in Africa, a population at high risk for HIV, has received little attention.

METHODS

This systematic review summarizes and discusses findings from 68 empirical studies, published between 1980 and 2016 that included data about substance use in men who have sex with men (MSM) in Africa.

RESULTS

Substance use has rarely been the primary focus of studies in African MSM. In general, measurement of substance use was suboptimal. Whereas prevalence of alcohol use varied across studies, partly resulting from variety in assessment strategies, it seemed higher than in the general male population across countries. Alcohol use was associated with sexual risk practices, but not with HIV infection. The most frequently reported drug used by African MSM was cannabis. The use of other drugs, such as cocaine and heroin seemed relatively rare, although injection drug use was exceptionally high in a few studies. As alcohol, drugs were regularly used in conjunction with sex. Both alcohol and drug use were often associated with other risk factors for HIV infection, including violence and transactional sex. No interventions were found addressing substance use among African MSM.

CONCLUSIONS

Given high HIV risk and prevalence in this population, substance use should be studied more in-depth, taking into account the specific social and cultural context. Assessment of substance use practices in this population has to be improved. The available information suggests, though, that there is an urgent need for interventions addressing substance use tailored to the needs of this critical population.

There has been little progress in implementing comprehensive alcohol control strategies in Africa

Alcohol is the most common substance of addiction and a threat not only to health but also to sustainable human development. Consequently, at least a 10% relative reduction in the harmful use of alcohol has been advocated by the World Health Organization (WHO). This perspective describes alcohol use in Africa, strategies to reduce harmful alcohol use, and the ability of African countries to meet this target. Although alcohol consumption in Africa was intermediate compared to other world regions, the total alcohol per capita among alcohol consumers was the second highest (19.5 liters); 19% of Sub-Saharan African men could be classified as binge drinkers. The alcohol industry is the key driver behind the uptake of alcohol use and misuse. The most cost-effective ways to reduce alcohol-related harm is to make alcohol less available and more expensive and to prohibit alcohol advertising. Most African countries have alcohol excise taxes, but these are not adjusted for inflation, meaning that the effectiveness of these taxes will likely decrease with time, leading to greater affordability. The majority of African countries do not have legally binding regulations for alcohol marketing. Alcohol misuse in Africa is not being addressed at a time when available strategies can efficiently and cost-effectively control alcohol-related harm.

The Health and Social Impacts of Easy Access to Alcohol and Exposure to Alcohol Advertisements Among Women of Childbearing Age in Urban and Rural South Africa

OBJECTIVE

The purpose of this study was to analyze the impact of easy access to alcohol and exposure to alcohol advertisements on women's alcohol consumption, reproductive history, and health and social outcomes in an urban and rural site in South Africa.

METHOD

Trained fieldworkers conducted face-to-face interviews with 1,018 women of childbearing age in the Moot, Mamelodi, and Eesterus areas of the City of Tshwane (Gauteng province) and in the rural Cederberg, Bergrivier, and Swartland municipalities (Western Cape province), recruited through random sampling and stratified cluster random sampling, respectively. Multivariate logistic regression analyses were conducted, stratified according to the urban and rural sites and controlled for four demographic factors.

RESULTS

In Tshwane, complications in the last pregnancy (odds ratio [OR] = 7.84, 95% CI [1.77, 34.80]), interpartner binge drinking (OR = 6.50, 95% CI [3.85, 10.94]), and community drinking (OR = 7.92, 95% CI [4.59, 13.65]) were positively associated with alcohol accessibility. Interpartner violence (OR = 4.16, 95% CI [1.99, 8.70]) and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements. In Western Cape, community drinking (OR = 10.26, 95% CI [4.02, 26.20]) was positively associated with alcohol accessibility, whereas ability to pay for health care (OR = 0.48, 95% CI [0.24, 0.96]) was inversely associated. Hazardous drinking on the Alcohol Use Disorders Identification Test (AUDIT; OR = 2.26, 95% CI [1.03, 4.95]) and CAGE (OR = 4.51, 95% CI [1.30, 15.61]), interpartner violence (OR = 1.69, 95% CI [1.04, 2.76]), and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements.

CONCLUSION

Easy access to alcohol and exposure to alcohol advertisements are positively associated with adverse health and social outcomes. Although further studies are needed, these findings lend support to emphasizing upstream policy interventions to limit access to alcohol and advertisements.

Caregiver alcohol use and mental health among children orphaned by HIV/AIDS in South Africa

Research in the developed world suggests that parental alcohol use negatively impacts child mental health. However, little research has examined these relations among children in the developing world and no studies to date have done so in the context of AIDS-orphanhood. Therefore, the present study tested the interactive effect of AIDS-orphan status with caregiver alcohol use on child mental health. The sample included 742 children (51.2% female; M_age= 9.18; age range: 7-11 years; 29.8 AIDS-orphans; 36.8% orphaned by causes other than AIDS; 33.4% non-orphaned) recruited from Mangaung in the Free State Province of South Africa. Child mental health was assessed via child self-report, caregiver, and teacher reports; and caregiver alcohol use via self-report. Path analyses, via structural equation modeling, revealed significant direct effects for AIDS-orphan status on caregiver-reported child mental health; and for caregiver alcohol-use problems on teacher-reported child mental health. However, the interaction effect of AIDS-orphan status with caregiver alcohol use did not reach significance on all three reports of child mental health problems. These results suggest that orphan status and caregiver alcohol use may independently relate to mental health problems in children and that the effects of both should be considered in the context of the mental health needs of children in AIDS-affected countries.

Couples living with and around alcohol abuse: A study of a farmworker community in the Cape Winelands, South Africa

RATIONALE

Low-income Coloured Western Cape communities in South Africa display high rates of problematic drinking, especially binge-drinking over weekends. Alcohol abuse in these communities is linked to the prevalence of intimate partner violence (IPV), fetal alcohol syndrome and sexual violence against women. Few studies, however, have investigated the social contextual factors that perpetuate alcohol abuse in these communities.

OBJECTIVE AND METHOD

Our study contributes to the need for social contextual knowledge need by providing an understanding of how committed couples, who lived and worked in one low-income historic farm worker community, located in the Cape Winelands of South Africa, constructed alcohol use and abuse in their relationship. Using a social constructionist grounded theory we analysed the consecutive interviews conducted with individual partners.

FINDINGS

Three themes shed light on our participants' alcohol use discourses. The first theme highlights participants' apparent lack of identification with the problem of alcohol abuse, despite the omnipresence of alcohol abuse in their accounts. The second theme draws attention to men's and women's explicit and implicit support of gendered norms regarding alcohol consumption. Linked to the previous, the third theme accentuate women's toleration of men's "quiet" weekend binge-drinking.

DISCUSSION

We point out the limitations of local alcohol policy and intervention efforts to address normative drinking discourses and practices in this research community.

Collective efficacy, alcohol outlet density, and young men's alcohol use in rural South Africa

Alcohol use contributes to morbidity and mortality in developing countries by increasing the risk of trauma and disease, including alcohol dependence. Limited research addresses determinants of alcohol use beyond the individual level in sub-Saharan Africa. We test the association of community collective efficacy and alcohol outlet density with young men's drinking in a cross-sectional, locally representative survey conducted in rural northeast South Africa. Informal social control and cohesion show protective associations with men's heavy drinking, while alcohol outlet density is associated with more potential problem drinking. These findings provide initial support for intervening at the community level to promote alcohol reduction.