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Alcohol and substance use among first-year students at the University of Nairobi, Kenya: Prevalence and patterns

Catherine mawia musyoka, anne mbwayo, dennis donovan, muthoni mathai.

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Competing Interests: The authors have declared that no competing interests exist.

* E-mail: [email protected]

Received 2019 Oct 1; Accepted 2020 Aug 11; Collection date 2020.

This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Increase in alcohol and substance use among college students is a global public health concern. It is associated with the risk of alcohol and substance use disorders to the individual concerned and public health problems to their family and society. Among students there is also the risk of poor academic performance, taking longer to complete their studies or dropping out of university.

This study determined the prevalence and patterns of alcohol and substance use of students at the entry to the university.

A total of 406 (50.7% male) students were interviewed using the Assessment of Smoking and Substance Involvement Test (ASSIST) and the Alcohol Use Disorder Identification Tool (AUDIT). Bivariate logistic regression analyses were used to examine associations between substance use and students' socio-demographic characteristics. Multivariate logistic regression analysis was conducted to examine the predictors of the lifetime and current alcohol and substance use.

Lifetime and current alcohol and substance use prevalence were 103 (25%) and 83 (20%) respectively. Currently frequently used substances were alcohol 69 (22%), cannabis 33 (8%) and tobacco 28 (7%). Poly-substance use was reported by 48 (13%) respondents, the main combinations being cannabis, tobacco, and alcohol. Students living in private hostels were four times more likely to be current substance users compared with those living on campus (OR = 4.7, 95% CI: 2.0, 10.9).

A quarter of the study respondents consumed alcohol and/or substances at the entry to university pushing the case for early intervention strategies to delay initiation of alcohol and substance use and to reduce the associated harmful consequences.

Introduction

Alcohol and substance use has continued to rise globally, more so among college students [ 1 ]. Statistics show a consistency of alcohol and substance use across countries. Globally, a total population of about 275 million people used a psychoactive substance at least once in 2016 [ 1 ]. In the United States of America (USA) the rate of substance is rising among those aged 18 to 25 years, with many of them being new users [ 2 ]. Alcohol, cannabis, and opioids are the most used substances by those aged 18 to 25 years in America [ 3 ]. In this age group, the daily use of marijuana was reported by 2.6 million users, while 3.4 million (10%) had alcohol use disorders [ 2 ]. In Europe an estimated 19.1 million young adults (aged 15–34) used substances in 2018 [ 4 ]; males used substances twice as much as females with cannabis being the most used substance [ 4 ].

In Africa studies conducted in universities in Nigeria, Uganda, Ethiopia and South Africa have found that the prevalence of alcohol and substance use ranged between 27.5% and 62%[ 5 , 6 ]. The prevalence of substance use among undergraduate students in one university in Nigeria was reported at 27.5% [ 7 ]. The United Nations Office on Drugs and Crimes (UNODC) 2018 report on substance use in Nigeria, puts the overall past-year prevalence at 14.3 million (14.4%) [ 1 ]. While use is reported across all age groups, the highest use was among the 25 to 39-year-olds and cannabis was the most used substance, with an average initiation age of 19 years; amphetamines and ecstasy use among young people was also reported [ 1 ]. Prescription opioids, mostly tramadol, morphine, and codeine, were also in high use; others included alcohol and tobacco use [ 8 ].

A higher prevalence of substance use, ranging from 20% to 68%, has also been found in different universities in Kenya [ 9 , 10 ].

A study at one Kenyan public university reported a substance use prevalence of 25.5%, with alcohol, cannabis, and tobacco being the most used substances [ 11 ].

Research shows that the transition periods from one life event to another are high potential entry points for youths to experiment with substance use and risky behaviours [ 12 ]. Students, aged between 18 to 25 years are at the transition point from high school education to college education [ 13 ]. This transition is associated with an increased risk for substance use initiation [ 14 ]. This risk in Kenya is exacerbated by the long waiting period students take to gain admission into the universities. During this waiting period, idleness may lead the youngsters to start experimenting with alcohol and substance use, behaviours which they may carry with them to the university. Furthermore, many of these students joining the university experience a new freedom from parental and teacher supervision. They additionally become responsible for larger sums of money than ever before in their lives [ 15 ]. The combination of these factors increases the susceptibility of the new students to harmful peer influence which may lead to alcohol and substance use initiation.

Age of onset of alcohol and substance use has dropped significantly worldwide from mean age 21 years in the mid-1980s to 10 years in 2012 [ 16 – 20 ]. The ages of 13 to 15 years are the critical years for the onset of substance use in Kenya [ 21 ]. Early initiation of substance use is positively predictive of the development of harmful immediate and long term consequences to the users [ 22 ]. Young people are particularly vulnerable to the harmful physiological effects of alcohol and substance use because of their immature body systems [ 20 , 23 ]. Psychologically, alcohol and substance use leads to disinhibition and a propensity for risky behaviours among young people [ 24 ]. This increases the risk of accidents and injuries, criminal behaviour, poor social relations, sexual assault, and risky sexual behaviour. In the long term, there is an increased risk of poor academic performance and the development of substance use disorders (SUD) [ 25 – 27 ].

Students who take alcohol and substances have been reported, more than their non-drug-using peers, to take longer to complete their studies, they get into trouble with university administration and some get expelled from the universities [ 28 ].

Universities, therefore, have to invest resources in the prevention and management of individuals with potential alcohol and substance use disorders to minimize the impact on their academic functioning and psychological wellbeing during their college years.

Programs for the prevention of alcohol and substances abuse are integral to many institutions of higher learning [ 29 ]. The strategies used include those aimed at universal prevention for those not yet using, selective prevention for those already experimenting with substances, and treatment of alcohol and substance use disorders for those suffering from harmful substance use [ 30 ]. The goal for universal prevention is to prevent young people from initiating substance use, while selective prevention is aimed at those at risk of problematic substance use [ 30 ]. In line with these practices, the University of Nairobi has a department on alcohol and substance abuse prevention that carries out activities to educate students on the negative effects of alcohol and substance use. There are also university counsellors who identify those students who abuse alcohol and substances and undertake counselling and rehabilitation [ 31 ]. Although the University has a policy of prohibiting alcohol or substance use in all its premises [ 31 ], students still get access to and use alcohol and other substances while at the university.

This study, therefore, aimed to determine the prevalence and patterns of alcohol and substance use of the students joining the University of Nairobi. The study findings will help guide universities to design and implement appropriate interventions for the prevention and management of alcohol and substance use among students.

Ethics and consent

The protocol was reviewed and approved by the Kenyatta National Hospital and the University of Nairobi Ethical Committee (KNH-UoN ERC) P98/02/2018. Written informed consent was obtained from all study participants.

This study was conducted at the University of Nairobi, which has 61,000 graduate and postgraduate students. Students are either publicly or privately sponsored. They may reside either in on or off-campus residences. The University of Nairobi has seven campuses located in Nairobi city and its environs ( www.uonbi.ac.ke ). The Chiromo and Kikuyu campuses were purposely selected as the study campuses. This choice was informed by previous surveys that have shown that students on these campuses have a high prevalence of substance use [ 32 ]. They were thus selected as the campuses that would provide the determination of the need for and design of prevention and intervention services. The selected campuses also have students who study varied courses in the sciences and humanities which were important to give a full representation of the study domains available in the university education system.

Study design and population

A cross-sectional study was done on first-year students of the academic year 2018/19 who joined the Kikuyu and Chiromo campuses of the University of Nairobi.

The students in the Chiromo campus take science-based programs like analytical chemistry, astronomy and astrophysics as well as environmental conservation and natural resources management.

Students in the Kikuyu campus take education-based courses like education science, physical education and education arts. These are all 4-year degree programs.

Sample size calculation

Using the Cochran’s formula for sample size calculation [ 33 ], a sample size of 406 respondents was obtained after adjusting for an anticipated 5% non-response rate. Given that Kikuyu campus had an enrolment of 1021 (45.3%) students and Chiromo campus had enrolled 1232 (54.7%) students, out of the sample size of 406, Chiromo proportionately contributed 222 (54.7%) and Kikuyu campus contributed 184 (45.3%).

Sampling procedure

Sampling probability to population size (PPS) strategy was employed. At the first stage, purposive sampling of the seven campuses of the University of Nairobi selected Kikuyu and Chiromo campuses. This selection was based on the documented high prevalence rates of alcohol and substance abuse among the students of these campuses [ 32 ].

At the second stage, total population sampling was done whereby all the six schools making up the Kikuyu and Chiromo campuses were studied. These schools are Education in Kikuyu, and Physical Sciences, Biological Sciences, Mathematics, Biotechnology and Computing in Chiromo.

At the third stage, the enrolment lists of first-year students in these schools were obtained and used to make the sampling frame for simple random sampling. The frame comprised 1,021 (45.3%) students in Kikuyu and 1,232 (54.7%) students in Chiromo. Kikuyu Campus with its one school retained the size of its frame for its School of Education. In Chiromo Campus the five schools had each allocated a population-proportionate sampling weight ( Fig 1 ). These various sampling frames were used for the third stage of sampling.

Fig 1. Flow chart of the sampling procedure.

Simple random sampling was applied to each of the constructed sampling frames. First, students were assigned a number starting from 1–1,021 in Kikuyu Campus and 1–1,232 in Chiromo Campus.

Random numbers were generated from the computer software Random.org and used to select study participants from each school. Secondly, the students in each school of Chiromo campus were randomly sampled by application of proportions to the population as summarized in Fig 1 . A final total of 406 study participants was selected.

Data collection

Data were collected between September and November 2018 using the World Health Organization (WHO) Assessment of Smoking and Substance Involvement Test (ASSIST) [ 34 ], the Alcohol Use Disorder Identification Tool (AUDIT) [ 35 ] and a researcher designed socio-demographic questionnaire.

Data collection tools

A researcher designed socio-demographic questionnaire was used to collect data on sex, date of birth, age, school of study, course of study, sponsorship (public or private), marital status and residence while studying. The ASSIST tool identifies more than 10 different types of substances including alcohol, cannabis, and tobacco, which are the most commonly used drugs by students [ 34 , 36 ]. Participants were asked if they had ever (lifetime) used alcohol and/or any of the listed substances and if the answer was affirmative, more detailed information was obtained about the previous 3-month frequency and consequences of use of the endorsed substances. The AUDIT-10 tool includes 10 questions that assess alcohol consumption and alcohol-related problems. Response options range from 0 to 4 and a summed total range from 0 to 40 scores. A score of 8 or more indicates hazardous or harmful or probable dependent drinking [ 37 ].

The consumption-related items assess binge drinking, defined by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) as the use of four or more standard drinks for women and seven or more standard drinks for men on any one occasion and at least once a week [ 38 ]. These tools have been validated for use in various settings involving a wide range of populations [ 36 ]. The validity and reliability of the ASSIST and AUDIT tools have been reported as good; they have been adapted for use in Kenya to investigate substance use among university students [ 10 , 39 ].

Questionnaire administration and retrieval

The questionnaires were administered in classrooms, 30 minutes before a lecture, with permission from the lecturer and assistance of the class representatives. All the students enrolled in a particular school were assigned a unique student number. These numbers were used to make a list. The randomization program ( Random.org ) was used to generate a list of those numbers to be selected. The students whose numbers were selected were then approached and requested consent to participate in the survey. If the student was not present in class on the day of data collection or if they declined to participate, the student whose number was next on the list was approached and requested to participate. This process was repeated until the required sample size of 406 was achieved. Filled questionnaires were collected by the principal investigator (PI) or research assistants and immediately checked for completeness. They were then transported and securely stored in a locked drawer, which accessible only to the PI to be retrieved later for further cleaning and data processing.

Variable measures

The main outcomes of alcohol and substance use were assessed as ‘Ever Used’ and ‘Current Use’. Following guidelines for the ASSIST, ‘current use’ was defined by consumption or use of alcohol or other substances in the immediate 3 months preceding the day of data collection. Patterns of alcohol use among the students were measured by the AUDIT-10.

Data management and statistical analysis

Data were coded and entered using the EpiData 3.1 software. It was checked for inconsistencies and missing values. Incomplete questionnaires were dropped at this point. The cleaned data were exported to Stata software. Data were stratified by study campus and school. The sampling scheme was self-weighing. All statistical analyses were performed using Stata software version 14.2 Special Edition. Stata survey suite was used to adjust for the stratification on data analysis.

Related questions were aggregated to indicate the prevalence of any alcohol or substance used in a lifetime and current use which was defined as use within the immediate 3 months before the day of data collection. Summaries of the lifetime and current use prevalence and social demographic variables were done using descriptive statistics such as mean and mode. Associations between the outcome variables for the lifetime and current use and the independent variables were examined by calculating odds ratios. The variables that were statistically significant at the p < 0.05 levels in bivariate analyses were used to create multivariate models. Multivariate logistical regression was used to assess the impact of explanatory variables on the outcome of the lifetime and current substance use prevalence, for women and men separately.

Baseline characteristics of the study respondents

A total of 406 study respondents consented to participate in the study. Table 1 presents the socio-demographic characteristics of the participants. Just over half (222/406, 54.7%) the respondents were registered for courses in Chiromo campus. By sex, approximately half of the respondents 206/406 (50.7%) were male.

Table 1. Social demographic characteristics of the study respondents.

The mean age of all respondents was 19.3± 1.2 years. The majority (371/406 (93.7%), were public sponsored and 318/406 (78.5%) resided on campus at university hostels.

Prevalence of substance use among the study respondents

The prevalence rates of substance use among the study respondents are as presented in ( Table 2 ). Overall 103 respondents (25.4%, 95% CI:21.21, 29.90) had ever used alcohol or another substance in their lifetime. Alcohol was the most used substance, having been ever used by 89/406, (21.9%, 95% CI:17.99, 26.27) of the study respondents in their lifetime. Cannabis was ever consumed by 33/406 (8.1%, 95% CI: 5.66, 11.23) of the study respondents. All the other groups of drugs listed (opioids, cocaine, amphetamines, hallucinogens, sedatives, and inhalants) had been used by (9.4%, 95% CI: 6.71, 12.62) of the respondents. Males had a higher prevalence of lifetime substance use at 63/206 (30.6%, 95% CI: 24.37, 37.36) compared to females at 40/200 (19%, 95% CI:13.81,25.13). This pattern was replicated across most substances assessed.

Table 2. Prevalence and associated confidence intervals by sex among the study respondents.

*opioids, cocaine, amphetamines, hallucinogens, sedatives, and inhalants.

The overall prevalence of recent substance use (reported use in the last three months) was 83/406 (20.4%, 95% CI: 16.62, 24.70). A similar pattern to that of ever use of substances was reported, with males’ current use of alcohol (22.8%,95% CI:17.27,29.16) being double the females’ rates of use for alcohol (11.00% 95% CI: 7.02, 16.18), this higher pattern of substance use among the males was replicated across most of the other substances ( Table 2 ).

Patterns of current substance use (use within last 3 months before the study)

The study participants who reported current alcohol use 42/406 (10.3%) drank twice or more times per month, 15/406 (3.7%) drank at least once a month while 8/406 (2%) drank alcohol every week and 4/406 (1%) drank daily ( Table 3 ). Weekly use of cannabis was reported by 6/406 (1.5%) of the users, while 13/406 (3.2%) used cannabis twice or more times per month. Out of the six respondents who reported use of cocaine two reported daily use, while the others used at least once a month ( Table 3 ).

Table 3. Patterns of substance use among study respondents within the last 3 months.

Predictors of current and lifetime substance use among study respondents.

Female first-year students had a significantly lower odds of current substance use compared to their male counterparts, (Odd Ratio (OR) 0.43(0.19–0.95), p<0.005) ( Table 4 ).

Table 4. Predictors of the lifetime and current substance use among study respondents adjusting for sampling weights.

*Significant at p≤0.05.

There was no significant difference in odds of current substance use between students who were government-sponsored compared to the privately sponsored ones. However, students who lived in private hostels were four times more likely to be current substance users as compared to those who resided in campus hostels (OR 4.40(1.14–16.86), p<0.005) ( Table 4 ).

The odds of current substance use by respondents from the School of Biological Sciences were five times those of the respondents from the School of Physical sciences (OR 5.10 (1.60–16.38), p<0.05) ( Table 4 ).

This study examined the prevalence, patterns, and predictors of the lifetime and current alcohol and substance use among first-year students at the University of Nairobi.

The overall lifetime substance use prevalence was found to be 25.4%. This is a considerably high rate, with nearly a quarter of the respondents using alcohol and other substances at admission to the university. The findings of this study are comparable with those of a similar study among students of Kenyatta University which found a lifetime substance use prevalence of 25.1% [ 11 ]. The comparability of findings may be due to students of the two universities being drawn from similar catchment populations as well as staying in the same urban settings.

The study findings are however, lower than those found in a study done among college students in Eldoret, Kenya, which found a lifetime substance use prevalence of 69.7% [ 9 ]. Given that the Eldoret study and the present one had respondents of similar age and education, differences in geographical locations and settings between Eldoret and Nairobi may explain the disparities of findings. Eldoret is located in a more rural setting as compared to the very metropolitan Nairobi, the capital city of Kenya. It is expected that students in the major cities have more vulnerabilities as well as opportunities for alcohol and substance use. Nevertheless, students in a major city may be more exposed to information on the negative effects of substance use due to connection to the internet and programs that target the prevention of substance use among university students. Moreover, the study done in Eldoret was done eight years earlier; a lot has changed in Kenya in terms of legislation concerning alcohol and substance use, and implementation of the Alcoholic Drinks Control Act 2010, revised 2012 [ 40 ].

The national prevalence of lifetime substance use in Kenya, for those aged 15–24 years, is 37.1% while the current substance use is 19.8% [ 19 ], these figures are higher than the lifetime substance use prevalence of 25.4% and 17% current substance use found by this study. However, this study found a higher prevalence of current alcohol and cannabis use at 17% and 5.2% compared to the Kenyan national prevalence of 11.7% and 1.5% respectively [ 19 ]. These higher trends of the current use of alcohol and cannabis by university students may be explained by the normalizing of substance use behaviour and aggressive marketing of alcohol and other substances among college students through digital platforms and social media like Facebook and WhatsApp, of which college students are prolific users [ 41 ].

The prevalence of substance use in studies across different geographical locations and social-economic environments in Africa showed comparable results to those reported by our study. In Northern Tanzania, a study by Francis et al reported a prevalence of current alcohol use of 45% among male college students and 26% among female students [ 42 ]. In South Africa, Ramsoomar et el , in a study done among adolescents at 13 and 18 years, found that the prevalence of lifetime use of substances rose from 22% at 13 years to 66% at 18 years [ 18 ]. A study among medical students in Nigeria reported a lifetime prevalence of use of mild stimulants of 46.1%, alcohol, 39.7%, and tobacco, 6% [ 43 ]. The prevalence of stimulant use in the Nigerian study was higher than the prevalence reported in our study. Besides, the use of alcohol is more common among our study respondents as compared to the use of stimulants. However, the prevalence rates of tobacco and cannabis were comparable to the findings in our study. This may be explained by the fact that all the study sites are in urban settings and the risks and exposures to substance use are comparable in most of the cities.

Prevalence studies done in European countries showed some similarities as well as contrasting findings. In France, a study among university students reported the prevalence of alcohol and tobacco consumption was at 20.1% and 23.2% respectively [ 44 ]. Studies among university students in nine member countries of the Association of South-East Asian Nations (ASEAN) found varying prevalence rates of illicit drugs, ranging from 0.2% in Cambodia to 45.7% in Laos [ 26 ]. The prevalence rates of our study fall within these ranges.

In the study among French students, even though the prevalence of alcohol use was comparable to the findings of our study, the reported 23.2% prevalence of tobacco consumption was higher than the 5.1% current use reported by our study. This difference in tobacco use among French study respondents and the respondents in our study may be accounted for by the tobacco control measures by the government of Kenya through the enacted Tobacco control act 2007 revised (2012), which has prohibited tobacco use in all public places among other controls [ 45 ]. These differences also support the premise that government legislation and enforcement are important in controlling substance use among young people.

The results for the prevalence of lifetime substance use by age showed a slightly higher rate among students who were 20 years and above compared to those aged below 19 years. There was, however, little difference in the prevalence of current substance use among students in the two age categories. Studies have shown that substance use behaviour is highest at the age of 18 to 24 years [ 46 ]. Young people at this age pursue their university education; at the same time, the age of initiation to alcohol and substance use has reportedly reduced in recent years [ 20 ]. In Kenyan studies, university students are among the leading categories of substance users [ 10 ].

There was a sex difference in the use of substances; males had higher rates of use in all categories of substances. These results are similar to those from other parts of the world in which males college students have been found to have higher rates of substance use than females students [ 5 , 42 , 47 ]. This trend may be a result of societies that are more tolerant of substance use among men as opposed to women.

The residence of the university students was associated with differences in the rates of substance use. The study results indicated that 48% of the students who reported current alcohol and substances use resided in private hostels.

Those who resided at home with parents were the second-largest users, while those who resided in university hostels reported the least substance use. These findings contradict an earlier study by Simons-Morton et . al , which found that students who resided in campus residences had the highest substance use [ 48 ]. The findings, however, are in agreement with a study that found that living in off-campus residences posed a high risk of alcohol use [ 49 ]. Private student hostels in Kenya do not have strict enforcement of rules regarding the use of alcohol and drugs in their premises. The landlords would not want to lose tenants by enforcing restriction measures on substance use by the student residents. This therefore, accords the resident students liberties to behave as they please, thus making them more vulnerable to substance use. This phenomenon could also be as a result of the difference in the social-economic status of students who reside in on or off-campus accommodation. In Kenya, students who reside in off-campus residences are often from a higher social economic background as compared to those using on-campus accommodation facilities. This underpins the need to have prevention interventions among university students target both on-campus and off-campus residents. Most of the preventive interventions for alcohol and substance use among university students focus on-campus facilities, this leaves out a vulnerable group in off-campus student residents.

The patterns of alcohol use found in the study also reveal that most students only used alcohol occasionally. This was most likely during the weekends when they socialize with their friends. This is of concern because these students often may take many substances at one sitting, as well as mixing different types of substances. Research evidence shows that students who binge drink are most likely to suffer acute and negative consequences of substance use [ 46 ]. There were 5% of students who reported regular use of alcohol, some even daily use. These students are of concern given that they are at great risk of having their substance use alter the cognitive and physical functioning. This potentially would lead to poor academic outcomes as well as violence and criminal activities as has been documented in previous studies [ 23 , 50 ].

Given the high number of students who used alcohol and other substances by the time they reported for university education, preventive interventions should start at the pre-university level. These levels include at high schools and home environments and they should be intensified throughout their university education period.

Current models of delivering alcohol and substance use prevention interventions include face-to-face interventions with the college students however, these are difficult to implement, because of the stigma associated with substance use. As a result, only 10–15% of college students receive the interventions needed to address their substance use problems [ 51 ]. Innovative and youth-friendly intervention strategies are key to prevent alcohol and substance use among university students [ 30 ]. The use of technology-based interventions would provide a more acceptable avenue to deliver evidence-based interventions to college students compared to face-to-face programs [ 30 ]. University management should explore all avenues to provide innovative strategies for the prevention of alcohol and substance use, as well as related negative consequences, among their students.

Strengths of the study

This study provides epidemiological information about the prevalence and patterns of alcohol and substance use among first-year university students. Furthermore, the results of this study have positive implications for strengthening interventions on substance use prevention among university students as well as a reference point for future comparative studies.

Limitations of the study

This study used a cross-sectional design and data; as such, this precluded any causal associations to be made on the factors associated with alcohol and substance use.

Also, the self-report measures employed in data collection may have led to recall and reporting bias as students may have given socially desirable responses, thus potentially leading to over/under-reporting of the prevalence of substance use.

To minimise on recall bias, we used pictorial charts of standard alcoholic drinks to aid the respondents. Moreover, we emphasized to the respondents the need to be truthful as their responses were confidential. This study was done on two campuses of a single public university; thus the findings may not be generalizable to other universities.

Conclusions and recommendations

This study demonstrated that the prevalence of alcohol and substance use among first-year university students at the Kikuyu and Chiromo campuses of the University of Nairobi is high. Interventions for the prevention and management of alcohol and substance use should therefore, start as early as at the entry to university. Thematic orientation programs are key to educate first-year university students on the negative effects of alcohol and substance use. Life skills training should be instituted to help students adjust and adapt to their university life well. Off-campus residence, advanced age, and male gender of university students were found to be positively predictive of their use of alcohol and other substances. Therefore, alcohol and substance use prevention intervention strategies should allow extra focus on these vulnerable sub-groups. Universities should also increase the available accommodation facilities for their students since living in on-campus residences was found to be associated with lower rates of substance use. This would also make prevention interventions among college students easier to implement.

We propose that programs for alcohol and substance use prevention and education should have a multi-sectoral approach, which should start at high school level and be intensified as the young adults join university education.

Supporting information

Acknowledgments.

We are grateful to the study participants for their genuine participation in this research and the research assistants for their commitment to this study.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

CMM received the research award "This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100113), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z) and Deutscher Akademischer Austauschdienst (DAAD). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the Fellow". www.aphrc.org www.cartafrica.org The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Interventions for adolescent alcohol consumption in Africa: protocol for a scoping review including an overview of reviews

• Alice M. Biggane 1 ,
• Eleanor Briegal 1 &
• Angela Obasi   ORCID: orcid.org/0000-0001-6801-8889 1 , 2  

Systematic Reviews volume  10 , Article number:  88 ( 2021 ) Cite this article

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Harmful alcohol use is a leading risk to the health of populations worldwide. Within Africa, where most consumers are adolescents, alcohol use represents a key public health challenge. Interventions to prevent or substantially delay alcohol uptake and decrease alcohol consumption in adolescence could significantly decrease morbidity and mortality, through both immediate effects and future improved adult outcomes. In Africa, these interventions are urgently needed; however, key data necessary to develop them are lacking as most evidence to date relates to high-income countries. The purpose of this review is to examine and map the range of interventions in use and create an evidence base for future research in this area.

In the first instance, we will conduct a review of systematic reviews relevant to global adolescent alcohol interventions. We will search the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science, Global Health and PubMed using a broad search. In the second instance we will conduct a scoping review by drawing on the methodological framework proposed by Arksey and O’Malley. We will search for all study designs and grey literature using the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science and Global Health, Google searches and searches in websites of relevant professional bodies and charities. 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. In both instances, the inclusion and exclusion criteria have been pre-defined, and two reviewers will independently screen abstracts and full text to determine eligibility of articles.

It is anticipated that our findings will map intervention strategies aiming to reduce 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.

Protocol Registration

This protocol was submitted to the Open Science Framework on May 03, 2021. www.osf.io/qnvba

Peer Review reports

Harmful alcohol use is a leading risk to the health of populations worldwide; it is a significant barrier to achieving many health-related targets of the Sustainable Development Goals (SDGs), including those for maternal and child health, infectious diseases, noncommunicable diseases, mental health and injuries and poisonings [ 1 ]. Alcohol use represents a key public health challenge in Africa where it accounts for more deaths and disability-adjusted life years (DALYs) lost than in any other region [ 1 , 2 ] and twice as many preventable deaths as tobacco [ 3 ].

Most alcohol consumers in Africa are adolescents and young people; the use is highly gendered, and adolescent males are at particular risk [ 4 ]. Evidence suggests that early alcohol initiation (aged < 14 years) predicts alcoholism in middle age [ 1 ] and is potentially a more powerful precursor to alcoholism than excess drinking in early adulthood [ 1 ]. Adolescents are more vulnerable to alcohol-related harm per volume than adults [ 1 ], and those who drink are more likely than their elders to engage in heavy episodic drinking (HED) (> 60 g alcohol at least once in the preceding month), which the WHO (World Health Organization) has identified as the most deleterious drinking pattern [ 5 ]. Alcohol use in adolescents is associated with alterations in verbal learning, visual–spatial processing, memory and attention as well as with deficits in development and integrity of the grey and white matter of the central nervous system [ 6 ]. These neurocognitive alterations are associated with behavioural, emotional, social and academic problems in later life [ 7 , 8 ]. Further, alcohol consumption in adolescence is associated with sexual risk taking [ 9 ], adverse HIV outcomes, self-harm, suicide and the perpetration of sexual violence [ 4 ].

Interventions to prevent or substantially delay alcohol uptake and decrease alcohol consumption in adolescence could significantly decrease morbidity and mortality, through both immediate effects and future improved adult outcomes [ 4 , 10 ]. These interventions are urgently needed in Africa; however, key data necessary to develop them are lacking as most evidence to date relates to high-income countries (HICs) [ 10 , 11 , 12 , 13 ]. We are aware of only one systematic review which included an evaluation of interventions to reduce adolescent alcohol consumption [ 14 ]; it featured one study from Africa [ 15 ]. This evidence gap was highlighted by Das et al. in their 2016 global overview of systematic reviews regarding adolescent substance abuse interventions including alcohol, in which they cautioned “there is a dire need for rigorous, higher quality evidence especially from low- and middle-income countries” [ 16 ]. This call has since been echoed by others [ 17 ]. The current review complements this work and specifically aims to map and characterise the specific adolescent alcohol interventions which have been used in Africa.

Types of intervention

Adolescent alcohol use is shaped by a complex range of factors acting at multiple levels in the environments in which adolescents grow and develop [ 18 ]. These levels of influence are commonly categorized in socio-ecological frameworks [ 18 , 19 ] as macro-system (e.g. policies, societal beliefs and cultures), community level (neighbourhood risks and resources), micro-system (households, schools, peer networks), and individual level (gender, age, socioeconomic status).

Figure 1 illustrates how interventions seek to exert effects or modify factors at one or more of these levels and how strategies used to deliver the interventions within settings (e.g. teachers and/or peers as educators in school-based programmes) vary. Theoretical models underpinning proposed mechanisms of action for intervention (e.g. Stages of Change model vs. Theory of Planned Behaviour) also vary. We will assess the available evidence for each type of intervention and identify evidence gaps to inform future research and implementation.

Intervention levels and example mechanisms of action

This review protocol has been registered within the Open Science Framework database (registration number: www. osf.io/qnvba ). Further, this review protocol is also being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement as appropriate which can be found in Additional File 1 [ 20 , 21 ].

The review will be conducted in two stages. First, in stage one, the proposed overview of systematic reviews will capture systematic reviews published since 2000 to complement Das et al.’s 2016 overview of systematic reviews [ 16 ] and provide the most up to date syntheses of the evidence base. This overview of reviews will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 [ 20 , 21 ].

Second, in stage two, the proposed scoping review of peer reviewed and grey literature published since 2000 will identify interventions and gaps in the evidence base relating to adolescent alcohol interventions in Africa. This will be reported in accordance with the PRISMA Extension for Scoping Reviews checklist (PRISMA-ScR) [ 22 ].

The methodologies for each of the above two stages are described in what follows. In both stages, interventions will be categorized by setting, delivery model and theoretical construct. Adolescents are defined as those aged 10–19 years; however, since many studies target youth (aged 15–24 years), we will include reviews and interventions targeting older groups if adolescents are also included. If possible, we will stratify our findings by age. Otherwise, we will report the combined results for adolescents and youth as representative of the population of interest. If we identify a new, relevant systematic review providing good quality evidence for appropriate interventions in Africa, we will at that point discuss the need for the scoping review and proceed as deemed appropriate.

Stage 1: Overview of systematic reviews

We will identify and review recent Cochrane and non-Cochrane systematic reviews of randomised or non-randomised controlled trials, which fully or partly addressed alcohol interventions for adolescents. For the purpose of this review, we have defined a systematic review as a review of evidence based on a clearly formulated question, to identify and critically appraise relevant research by following a systematic, explicit and repeatable methodology [ 23 ].

Eligibility criteria

We will develop a comprehensive search strategy to review the available literature underpinned by our pre-defined inclusion criteria (Table 1 ).

Our pre-defined exclusion criteria are as follows:

No information on an alcohol use intervention

Duplicate publications

Reviews other than systematic, e.g. narrative, scoping

Grey literature

Published before 2000

Interventions that were not purposely developed to target adolescent alcohol consumption

Interventions that were exclusively targeting individuals aged 25 years or more

Identifying relevant studies

We will search the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science, Global Health and PubMed for publications published from January 2000 onwards, using a broad search strategy building on that outlined by Das et al. [ 16 ] in their 2016 overview. This will include a combination of appropriate keywords, medical subject headings (MeSH terms) and free text terms; an outline of our search strategy for PubMed is available in Additional File 2 ; it will be updated accordingly for the other databases. We will also examine cross-references and bibliographies of included publications to identify additional sources of information. If required, we will contact the publication’s lead author to clarify or seek additional information. All articles identified from the literature search will be screened by two reviewers independently. First, titles and abstracts of articles returned from the initial searches will be screened based on the eligibility criteria outlined above. Second, full texts will be examined in detail and screened for eligibility. Third, references of all considered articles will be hand-searched to identify any relevant publication missed in the search strategy. Any disagreements on selection of reviews will be resolved via discussion and if needed the input of a third reviewer. A flow chart showing studies included and excluded at each stage of the screening process will be included in the full publication [ 24 ].

Extracting and charting the data

After retrieval of the full texts of all the reviews that meet the inclusion criteria (Table 1 ), data from each review will be extracted, independently by two reviewers, in a standardised form using Microsoft Excel. Data we will collect includes but is not limited to:

Author(s), year of publication, publication type, study location

Study populations—characteristics and locations

Aims of study

Intervention details building on the TIDieR Format [ 25 ] (name, rationale/theory, materials, provider, mode, context (e.g. school/community/clinic), intensity and duration, tailoring, modification, fidelity)

Comparator (if any)

Target demographics (gender, age, i.e. older/younger adolescents (10–14/15–19))

Geographical location—country

Setting (e.g. urban/rural)

Outcome measured

Measurement of treatment effects

Inclusion and exclusion criteria

Risk of bias tool

As shown in Fig. 1 , the types of intervention will vary, and we anticipate that some may be complex interventions operating at more than one ecological level. For example, community-based interventions aimed at decreasing alcohol availability for adolescents may be combined with school-based programmes targeting individual knowledge. The latter maybe delivered by teachers or peer educators.

These elements and any other relevant information regarding the intervention programmes (socio-ecological level, setting, delivery mechanism, target group, behaviour change theory), acceptability and costs will be extracted. When there is missing data, we will attempt to contact the original authors to obtain the relevant information. We do not have any pre-planned data assumption or simplifications. We will extract pooled effect size for the outcomes reported by the review authors with 95% confidence intervals (CIs). We will assess and report, in duplicate, the quality of included reviews using the 11-point assessment of the methodological quality of systematic reviews (AMSTAR-2) criteria [ 26 ]. We will report the final results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting tool [ 24 ].

Data analysis

We will analyse the data arising from all included publications to create an overview of the various adolescent alcohol interventions being used global and their reported effectiveness and location. We plan to analyse the data using descriptive statistics via Microsoft Excel and report the findings narratively, using tables to characterise key features, interventions and findings. We will also seek to identify whether interventions were exclusively designed to target alcohol consumption or were part of a wider substance abuse or healthcare intervention. Where possible, we will explore both the variations and overlap that may exist in findings of the reviews, as well as issues such as the numbers of studies included, date ranges covered by the reviews, sample sizes, target populations and settings. However, we will be adaptive to the data we extract and the subsequent analysis as appropriate.

• Scoping review

A scoping review will allow us to identify and map the range and type of interventions as described in Fig. 1 [ 24 , 27 ]. A strength of this type of review is that, in addition to published articles, we will also search for grey literature, such as reports and guidance documents as it is possible that some of the information being sought (i.e. descriptions of alcohol interventions in use) for our target population are documented in non-traditional forms of scientific publications. In designing our scoping review protocol, we draw on Arksey and O’Malley’s methodological framework [ 27 ] and its amendments [ 28 , 29 ] as follows.

Identifying the research question

Based on gaps in the literature and the study team’s knowledge of the field these are as follows:

What interventions have been used to delay, reduce or otherwise modify alcohol consumption among adolescents in Africa?

What are the settings, delivery methods, theoretical bases and reported effectiveness of these interventions?

These questions will be refined, or new ones added, as the researcher team becomes familiar with the literature [ 27 ].

We will develop a comprehensive search strategy to review the available literature using the ‘Population–Concept–Context (PCC)’ framework for scoping reviews [ 30 ], underpinned by our pre-defined inclusion criteria (Table 2 ).

Protocol only

Not used in Africa

Drawing on the three-step process recommended by JBI [ 29 ], we will systematically search the following databases: Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science and Global Health for relevant publications from the year 2000 onwards. We will also perform targeted searches for grey literature published from the year 2000 onwards, by searching (1) Google, (2) relevant discipline-based listservs (e.g. academic institutes) and (3) the websites of agencies that fund or implement public health interventions in Africa (e.g. ministries of health, charity organisations). Relevant blogs, newsletters, reports and surveys will also be considered.

The draft literature search for MEDLINE (Ovid) can be found in supplementary information Additional File 3 , which uses a combination of keywords, MeSH and free text terms; it will be updated accordingly for the other databases. Intervention types will not be included in the search to avoid limiting the results. We will review potentially relevant text words in the titles and abstracts of important papers in the field, thus compiling a list of terms that can be used to inform our search strategy. The literature search will be supplemented by handsearching of the reference lists of included studies for keywords and contacting methodological experts in each field. The search strategy and its iterations will be peer reviewed by a health librarian specialist using the Peer Review of Electronic Search Strategies (PRESS) checklist [ 31 ]. There will be no language restrictions and relevant articles will be translated into English as needed.

Study selection

All identified records (titles and abstracts) will be collated in a reference manager for de-duplication. The abstracts (and the full sources where abstracts are not available) will be screened by two reviewers to identify relevant literature based on our a priori inclusion criteria. Neither of the review authors will be blind to the journal titles or to the study authors or institutions, after which we will retrieve the full text of all potentially eligible articles, which will also be independently screened. Any disagreements during screening will be resolved via discussion and if needed the input of a third reviewer. The final unique set of records will be imported into an Excel file to facilitate independent screening and log disagreements between reviewers. We will also record reasons for exclusion at the full-text review stage.

We expect that some of the grey literature might subsequently be published elsewhere in the indexed literature. This will be accounted for by cross-checking authors’ names across grey literature and index literature results to identify potential duplicates.

Charting the data

We will develop a charting form to aid the collection and recording of key information using Excel, this will be done in duplicate. We will record the following:

Study populations

Intervention type, and comparator (if any); duration of the intervention

Demographics (gender, age, i.e. older/younger adolescents (10–14/15–19))

Setting (e.g. urban/rural, school/community/clinic)

Methodology

Important results

The information from research-based and non-research-based publications will be collected in separate extraction forms. Additional categories that may emerge during data extraction will be added accordingly.

Collating, summarising and reporting the results

We will combine all relevant findings from the data retrieved across the various sources to create a useful summary which identifies and maps relevant interventions and their characteristics. This will include general and specific descriptions of the interventions, the population targeted, the delivery methods, the reported effectiveness and lessons learned where possible. Further, we will also extract relevant data surrounding development of the intervention and resources required. We plan to analyse the data using descriptive statistics via Microsoft Excel and report the findings narratively. If appropriate, we will include tables describing key features. If possible, and dependent on the number of studies retrieved and included, we will include a geographical map showing areas in which interventions have been used. We will also look for overlap and variations between the studies in terms of intervention type, results, setting, population targeted and follow-up timeframe. However, we will be adaptive to the data we extract and the subsequent analysis as appropriate. It should be noted that this study will not assess the quality of evidence and therefore cannot comment on the generalisability and robustness of individual studies [ 27 ]. We will report the final results using the PRISMA Extension for Scoping Reviews checklist (PRISMA-ScR) [ 22 ].

Any amendments to this protocol when conducting the study will be outlined in Open Science Framework and reported in the final manuscript.

Our scoping review including an overview of reviews will systematically identify and map the interventions used to target adolescent alcohol use in Africa. Both stages of our review will be of value to a range of stakeholders in the field of adolescent alcohol use. Our characterisation of the different interventions that exist, the degree to which each has been implemented and tested and the gaps and priority research questions identified will be relevant to a variety of audiences including researchers, public health practitioners, policy makers and charity organisations.

Publication of this research protocol is in keeping with good, transparent research practise, as it reduces the risk of bias and selective reporting while providing an opportunity to strengthen our proposed review.

We do not anticipate any practical or operational issues arising that will affect the performance of this study as our research team has experience and knowledge of both the subject matter and the methodology. We will make our data available to other researchers by request. One potential limitation of this study is the difficulties that exist in categorising adolescents in terms of age; however, by including studies with participants up to the age of 24 years and stratifying our results as possible, we should capture all relevant populations as previously outlined in this protocol.

As there are no human participants involved, there will be no requirement for ethical approval. Patients and/or the public were not involved in the design of this protocol; however, the authors will work with patients and members of the public through stakeholder and other PPI research forums in disseminating the findings of the review both in the UK and the Global South.

Findings will be disseminated widely through peer-reviewed publication and in various media, for example, conferences, congresses or symposia. This review will inform other researchers in the field of adolescent health as a standalone piece of work but will also provide a baseline resource which can be used to inform future research planning.

Availability of data and materials

Not applicable

Abbreviations

Assessment of the Methodological Quality of Systematic Reviews

Disability-adjusted life years

Heavy episodic drinking

High-income countries

Joanna Briggs Institute

Population, Concept, Context

Peer Review of Electronic Search Strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

Sustainable Development Goals

World Health Organization

Global status report on alchohol and health 2018. World Health Organisation; 2019.

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Acknowledgements

The authors would like to thank Camila Olarte Parra, Alison Derbyshire and Professor Paul Garner for providing advice during the writing of this protocol.

This research was funded by the National Institute for Health Research (NIHR) (project reference 16/136/35) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care. The funders had or will have no role in the development of this protocol, the collection and analyses, or interpretation of results, or in the writing or publication of the review’s results.

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Alice M. Biggane, Eleanor Briegal & Angela Obasi

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All authors have made substantive intellectual contributions to the development of this protocol. AB, EB and AIO jointly conceived the idea for the project. AB, EB and AIO contributed to the study design and development of research questions. AB conceptualised the review approach and led the writing of the manuscript. AIO led the supervision of the manuscript preparation. All authors provided detailed comments on earlier drafts and approved this manuscript. AIO is guarantor of this review.

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Biggane, A.M., Briegal, E. & Obasi, A. Interventions for adolescent alcohol consumption in Africa: protocol for a scoping review including an overview of reviews. Syst Rev 10 , 88 (2021). https://doi.org/10.1186/s13643-021-01642-4

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• Volume 14, Issue 2
• Prevalence of alcohol use and associated factors since COVID-19 among school-going adolescents within the Southern African Development Community: a systematic review protocol
• Article Text
• Article info
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• http://orcid.org/0000-0001-7088-8357 Tshepo A Ntho 1 ,
• Mahlapahlapana J Themane 2 ,
• Medwin D Sepadi 2 ,
• Talamo S Phochana 3 ,
• http://orcid.org/0000-0001-7592-5145 Tholene Sodi 3 ,
• http://orcid.org/0000-0002-8720-2355 Emmanuel Nii-Boye Quarshie 4 , 5
• 1 Nursing Science , University of Limpopo , Polokwane , Limpopo , South Africa
• 2 Department of Education Studies , University of Limpopo , Polokwane , Limpopo , South Africa
• 3 SAMRC-DSI/NRF-UL SARChI Research Chair in Mental Health and Society, Faculty of Humanities , University of Limpopo , Polokwane , Limpopo , South Africa
• 4 Psychology , University of Ghana College of Humanities , Accra , Ghana
• 5 School of Medicine, Faculty of Medicine and Health , University of Leeds , Leeds , UK
• Correspondence to Tshepo A Ntho; tshepo.ntho{at}ul.ac.za

Introduction The COVID-19 pandemic has significantly shaped the global landscape and impacted various aspects of individuals’ lives, especially the behaviour of school-going adolescents regarding substance use. Among these substances, alcohol is the most predominant substance, particularly among school-going adolescents, who also are highly susceptible to harmful alcohol use, such as poor academic performance, psychiatric disorders and disrupted social lives. This review will synthesise the known prevalence estimates and associated factors of alcohol use among school-going adolescents in the Southern African Development Community (SADC) since the COVID-19 pandemic.

Methods and analysis We will perform a systematic review in line with the Cochrane Handbook for Systematic Reviews. We will systematically search for selected global databases (ScienceDirect, EbscoHost, PsycINFO and PubMed) and regional electronic databases (African Index Medicus, Sabinet and African Journals OnLine). Peer-reviewed literature published between 11 March 2020 and 10 March 2024 will be considered for eligibility without language restriction. All 16 countries of the SADC region will be included in the review. The Mixed-Methods Appraisal Tool checklist for quality appraisal will be used to appraise the methodological quality of the included studies. Depending on the level of heterogeneity, prevalence estimates will be pooled in a meta-analysis; narrative synthesis will be applied to describe the reported associated factors of alcohol use.

Ethics and dissemination We will not seek ethical approval from an institutional review board since the study will not involve gathering data directly from individual school-going adolescents, nor will it violate their privacy. When completed, the full report of this review will be submitted to a journal for peer-reviewed publication; the key findings will be presented at local and international conferences with a partial or full focus on (adolescent) alcohol (mis)use.

PROSPERO registration number CRD42023452765.

• adolescents
• substance misuse

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-080675

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The cross-national nature of this review covers countries in the Southern African Development Community (SADC) region, allowing for comparisons of findings across and within these countries.

This review will employ a meticulous search strategy to locate and retrieve studies relevant to our research question.

A plausible lack of extensive published primary studies on alcohol use among school-going adolescents in the SADC region may result in insufficient (eligible) papers.

Introduction

Alcohol abuse is a persistent global problem. WHO estimates that harmful alcohol use results in 3 million deaths each year worldwide, which represents 5.3% of all deaths, but the global usage of alcohol is also reported to be on the rise among school-going youths and adolescents. 1–5 For instance, a recent report by WHO indicates that over 25% of individuals aged 15–19 years consume alcohol. 6 This translates to about 155 million adolescents who consume alcohol. The consumption of alcohol by adolescents is a significant public health concern due to its adverse impact on their physical and mental well-being. 2 7 Notably, recent studies have shown that there has been an increase in alcohol use among school-going adolescents during the COVID-19 lockdown period. 8 9 While several efforts have been made globally (during and in the post-COVID-19 era) to control and prevent adolescent alcohol (mis)use, the problem persists. 10–12

So far, the studies that exist on this problem are sporadic and scattered, especially in the Southern African Development Community (SADC) region. In particular, secondary studies synthesising what is known about the problem in the region are unavailable. SADC is a regional organisation that promotes economic integration among its 16 member states: Angola, Botswana, Comoros, Democratic Republic of Congo, Eswatini, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, United Republic of Tanzania, Zambia and Zimbabwe. The community aims to enhance sustainable development, increase economic growth and reduce regional poverty through various programmes and initiatives. 13 SADC seeks to promote economic growth, social progress, poverty eradication and to attain an acceptable standard of health for all citizens. 13 Significantly, school-going adolescents from the SADC are no exception to increased alcohol use, particularly during the COVID-19 pandemic. 14

It is important to note that this review defines adolescence as a period of human development that usually lasts from 12 to 24 years. 15 During this period, individuals begin to explore their own identity and sense of self, which can lead to extended periods of confusion about their identity. The literature suggests that adolescents experience rapid physical, cognitive and psychosocial growth, which affects how they feel, think, make decisions and interact with the world around them. 15–17 Clearly, during the adolescence stage, individuals often experience prolonged periods of identity confusion. Chao argued that this could lead to engaging in risky behaviours without fully considering the potential consequences of their actions. 18 Engaging in risky behaviour can involve the use of substances like alcohol. During the COVID-19 pandemic, many school-going adolescents faced increased vulnerability and exposure to various challenges, leading to increased use of substance such as alcohol. 19 20 Oppong Asante et al observed that during the COVID-19 lockdown, despite restrictions on alcohol sales and human movements, it appears that the use of alcohol did not decrease or stop. 21

The increase in alcohol consumption among adolescents has been attributed to several factors, including certain social norms, personal disposition and the impact of the COVID-19 pandemic. 22–24 Other studies have also indicated that closure of schools and other hardships caused by the COVID-19 pandemic have led to suicidal thoughts in young people, with some individuals turning to alcohol and drugs to escape anxious thoughts about the pressures of the pandemic and fatalistic thinking. 19 20 25–31 The closure of schools during the COVID-19 pandemic was particularly troubling for young people (including those living within SADC), given that schools are considered safe havens and secure spaces for pupils. Schools offer nutritional meals and a secure environment that helps students escape unpleasant experiences at home and in neighbourhoods. 28

Alcohol use has emerged as a critical global concern, causing a significant impact on public health and socioeconomic development, particularly in low-income and middle-income nations. 32 According to WHO, alcohol use involves the consumption of non-medicinal psychoactive substances like beer, wine and whiskey. 33 Alcohol is widely used in various cultures, and it can be addictive. It is well documented that excessive consumption of psychoactive substances found in alcoholic beverages can be harmful among young populations, including school-going adolescents. 34 35 There is a direct connection between alcohol consumption and negative behavioural outcomes, whether intentional (eg, self-injury, aggression towards others) or unintentional such as road accidents and unintended self-poisoning. 34 36

In Africa, there has been a noticeable increase in the consumption of alcohol per person, especially among adolescents, which has led to a rise in alcohol-related illnesses. 24 37–39 Pooled estimates from sub-Saharan Africa suggest the highest proportion of alcohol use among adolescents is in Southern Africa (40.82%), followed by East Africa (34.25%), then Central Africa (29.09%). 32 In contrast, West Africa had the lowest proportion of alcohol use among adolescents at 28.21%. The rise in alcohol use among school-going adolescents is linked to experiences of hunger, bullying, physical fights, material influence and parental substance abuse. 2 21 40 41 As a global public health and social problem, the prevention of adolescent alcohol use requires governments in sub-Saharan Africa and other regions of the world to consider scaling up interventions for the prevention and treatment of substance abuse in line with the Sustainable Development Agenda 2030. 42 This objective highlights the vital role that alcohol plays in the global disease burden, which poses a significant challenge to attaining global development goals. In line with target 4.1 of the Sustainable Development Goals (SDG) set to be achieved by 2030, the aim is to guarantee that every child, along with adolescents, gets access to quality primary and secondary education and completes it. 42 However, if left unchecked, adolescent alcohol use threatens the attainment of this SDG target, as alcohol use contributes to truancy, high attrition and increased dropout rates among school-going adolescents. 43 44

Since the COVID-19 pandemic, alcohol use has been a mounting problem that demands urgent attention. Some associated factors include family, school, adolescent variables and economic factors. 45 46 For instance, alcohol use among adolescents is greatly influenced by negative attitudes towards school, behavioural problems, sociocultural influences and peer pressure. 47 Mmereki et al have also identified sex, age, school grade, repeating a grade and working during spare time as contributing factors to adolescent alcohol use. 35 Thus, there is a need to have a synthesised understanding of the prevalence and associated factors of alcohol use among school-going adolescents since the COVID-19 pandemic to inform the conceptualisation of preventative and interventive efforts and programmes. Schools are effective in implementing behaviour change programmes among adolescents, which will have a long-term impact. 12 For effective intervention among school-going adolescents, there is a need for evidence of the prevalence and associated factors of alcohol use among school-going adolescents since the COVID-19 pandemic. The effect of COVID-19 is not highlighted in conducted reviews that looked at the prevalence of alcohol use among school-going adolescents. 11 Also, other reviews combined data from adolescents, youth and adults, and were not confined to the member countries of SADC. 10 For example, a review published nearly half a decade ago was limited to sub-Saharan African countries. 32

Although member countries of SADC also fall under sub-Saharan Africa, it is significant to understand the prevalence of alcohol use among school-going adolescents specifically in the SADC region, as member countries of SADC share some comparatively similar health-related characteristics. Therefore, this proposed systematic review will assist in planning and developing effective interventions and achieving the SADC Health Policy Framework, which prioritises combating violence and substance abuse. Furthermore, the review can significantly enhance the utilisation of evidence in policy formulation and decision-making at the SADC regional level. 48 To the best of the authors’ knowledge, this is the first effort to systematically review and synthesise the existing literature on alcohol use among school-going adolescents from the SADC region.

Theoretical framework

Our approach involves providing an understanding of various influences on adolescent alcohol use through the socio-ecological theoretical framework originally proposed by Bronfenbrenner 49 to understand human development. The socio-ecological framework posits that many factors across the microsystem, mesosystem, exosystem, macrosystem and chronosystem influence human development in a reciprocal fashion. 49 The socio-ecological framework has been applied to understand human health behaviour and pro-health promotion intervention programmes. 50 McLeroy et al have suggested five levels of interacting ecological layers which determine human health-related behaviour: individual/intrapersonal factors (related to biological and personal history); interpersonal factors, which relate to formal and informal social networks including support systems such as family, peers, working groups and friendships; institutional factors , which include organisational characteristics, social institutions, rules and regulations; community factors and public policy level , which involves national laws or state and local policies. 50 The socio-ecological model has been found useful in understanding alcohol use among the general population. 51–53 More recently, the model has proven useful in understanding the protective factors and risks associated with alcohol use among school-going adolescents in countries within sub-Saharan Africa. 54 55 Thus, Asante and Quarshie highlighted the importance of considering various levels of influence when studying and comprehending the health behaviour of school-going adolescents. 5 This includes considering individual levels, immediate and broader community and societal levels. Therefore, to fully understand the phenomenon of alcohol use among adolescents, it is imperative to consider the influence of the adolescents’ personal/individual level, family level, school level, interpersonal/peer relationship level and community/neighbourhood level. As Asante and Quarshie argued, these factors influence substance use behaviour, including alcohol (mis)use. 5 Based on this theoretical framework, this systematic review aims to determine the prevalence and associated factors of alcohol use among school-going adolescents since the outbreak of the COVID-19 pandemic, which has had significant impacts on people’s lives.

The objectives of this systematic review are:

to synthesise the prevalence estimates of alcohol use since COVID-19 pandemic among school-going adolescents within the SADC region;

to describe the known factors associated with alcohol use since COVID-19 pandemic among school-going adolescents within the SADC region.

We followed the guidelines suggested by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement to report this review protocol. 56 The reporting of the completed review would be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 57 guidelines. 57 In brief, our approach involves using predetermined eligibility criteria, search strategies, guidelines for extracting data, conducting critical appraisals, synthesising data and reporting results.

Eligibility criteria

We have formulated the eligibility criteria by mainly following the population, exposure and outcome (PEO) model. 58 Table 1 outlines the specific exclusion and inclusion criteria that will be used to select eligible papers for this review.

• View inline

Summary of eligibility criteria

Electronic databases information sources

Our electronic database search filter will span from 11 March 2020 (when initial cases of COVID-19 were recorded within SADC) to 10 March 2024 (the anticipated completion date of this review). We will search four global electronic databases (ScienceDirect, EBSCOhost, PsycINFO and PubMed) and three regional electronic databases (African Index Medicus, Sabinet and African Journals OnLine) for potentially eligible studies. As part of this systematic review, we will search for additional records by examining the reference lists of identified eligible publications. We will search Google Scholar, the South African Institutional Repository database and the Cochrane Library to find any primary studies that are relevant records. We will contact pertinent study authors for further details if needed. The reporting of the literature search process will adhere to the Statement for Reporting Literature Searches in Systematic Reviews (PRISMA-S) guidelines. 59

Search strategy and process

The search strategy would include keywords, Boolean logical operatives, truncations and Medical Subject Headings terms as appropriate for and relevant to each selected database. Although the review would be reported in English, the search for and screening of potentially eligible records will be performed without any language restriction. Our geographic search filter would include the names of the 16 countries within SADC. For example, we will search the PubMed database using the following search strategy (see online supplemental material ) optimised through the assistance of an institutional librarian at the University of Limpopo, South Africa: (“alcohol use” OR “alcohol abuse” OR “substance abuse” OR “alcohol dependence” OR “alcohol addiction”) AND (associated factors OR correlates OR risk factors OR contributing factors OR protective factors) AND (adolescent* OR teen* OR child* OR young people) AND (school going OR “in-school adolescents” OR “school-going adolescents” OR school-attending OR school-based OR school learners OR students OR pupil) AND (Angola OR Botswana OR Comoros OR “Democratic Republic of Congo” OR Eswatini OR Swaziland OR Lesotho OR Madagascar OR Malawi OR Mauritius OR Mozambique OR Namibia OR Seychelles OR South Africa OR United Republic of Tanzania OR Zambia OR Zimbabwe).

Supplemental material

Study records.

All authors have received training to ensure a basic understanding of systematic reviews. Once the electronic search is complete, the records will be integrated and managed by EndNote software (V.21). Two authors (TAN and MDS) will each independently review the titles and abstracts of accessed records. We will obtain the full text of all possibly relevant studies for further assessment by four authors (TAN, MDS, MJT and TSP) within the lenses of the eligibility criteria. Excluded studies will be recorded with explanations. Any discrepancy will be resolved by discussion among the four authors; where necessary, two authors (EN-BQ and TS) would be consulted for arbitration. Similarly, authors of eligible studies would be contacted (via email correspondence) for additional information and clarifications where needed. Furthermore, this review will use a study PRISMA-2020 flow diagram format to present the searching and screening of records.

Data collection and data items

The steps involved in the data collection process are as follows: initially, after importing the studies into EndNote (V.21), the primary data extraction will occur. We will design a data extraction form with columnal spaces for author(s) and the year of publication, the country of study, the objectives, study design, sample size, key findings and study quality rating.

Risk of bias in individual studies

We will use the Mixed Methods Appraisal Tool checklist for quality appraisal of the eligible studies. 60 Two authors (TAN and MDS) will each independently fill the checklist on the appraisal tool. Any discrepancy will be resolved by discussion between the two authors (TAN and MDS) and the third author (MJT) will be consulted for arbitration when necessary.

Data synthesis

A decision to pool the prevalence estimates in a meta-analysis would be based on the extent of heterogeneity (I 2 statistic) across the included prevalence studies. 61 If a high I 2 statistic (>70%) is obtained, no meta-analysis will be performed; in that case, the estimates would be synthesised descriptively using the IQRs and associated median values of the reported prevalence rates. Where low-to-moderate I 2 statistic (≤70%) is obtained, the prevalence estimates would be pooled in a meta-analysis—in a random effects model—using the Jamovi software (V.2.4.11 for Windows). 62 We will analyse subgroups separately if authors find differences in clinical and methodological factors. Otherwise, we will not combine the data, but instead, a detailed summary will be created using a narrative-qualitative approach to provide a comprehensive overview of the factors associated with alcohol use reported in the studies included.

Subgroup analysis

If we find enough studies that are similar, we will conduct a subgroup analysis. Our intention is to categorise the findings based on the reported prevalence, and associated factors of alcohol use among school-going adolescents.

Sensitivity analysis

We will use the leave-one-out method to identify the cause of heterogeneity in a dataset with significant variations. In this approach, we will exclude one study at a time and check if the level of heterogeneity decreases. By conducting this test on each study, we can pinpoint the source of the heterogeneity.

Ethics approval is not required since the study will not involve gathering data directly from individual school-going adolescents, nor will it violate their privacy.

This systematic review will provide an assessment of the current state of the prevalence of alcohol use among school-going adolescents in the SADC region and its associated factors since the emergence of the COVID-19 pandemic. Conclusions drawn from this review may benefit school-going adolescents who use alcohol by helping them understand the evolving factors associated with alcohol use and its implications in the context of the pandemic and the aftermath. Moreover, the findings may offer valuable insights to support clinicians and educators in diagnosing or identifying school-going adolescents with alcohol use tendencies, considering the potential changes brought about by the pandemic. Policymakers and leaders might also gain essential information to develop appropriate prevention guidelines that account for the unique challenges posed by COVID-19. The results of the proposed systematic review could identify gaps in knowledge and provide a roadmap for future research aimed at improving outcomes for school-going adolescents facing alcohol use problems during pandemics.

While amendments to the methods of this proposed review are not expected, in the event of any needed changes to the protocol, we will describe them in the ‘Amendments’ section of this protocol the changes necessary and their justification, plus the date of each change. The PROSPERO registration for this review would also be amended to reflect all important corresponding changes to the protocol. All amendments would be approved by the authors.

Ethics statements

Patient consent for publication.

Not applicable.

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• Zlowodzki M ,
• Poolman RW ,
• Kerkhoffs GM , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

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Contributors All authors have contributed to the conceptualisation of the study. The manuscript protocol was drafted by TAN, MDS, MJT and TSP and was revised by TS and EN-BQ. All authors collaborated on developing the search strategy. MDS and TAN will independently screen potential studies, extract data from included studies, assess bias risk and synthesis data. MJT and TSP will resolve disputes and prevent errors in the study. All authors approved the protocol’s publication.

Funding The National Research Foundation supported this systematic review under grant number: NRF150768. The study's funder did not participate in the study's design, writing of the study protocol or submission of the study for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Related Topics

• Alcohol abuse
• Alcohol advertising
• Alcohol consumption
• Binge drinking
• Public health
• Underage drinking
• Youth drinking

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Research Fellow, Centre for Alcohol Policy Research, La Trobe University

Professor, The Centre for Social Research on Alcohol and Drugs, Stockholm University

Professor of Alcohol Policy, Sheffield Alcohol Research Group, University of Sheffield

Chief Specialist Scientist in Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council

University of Cape Town

Researcher, Karolinska Institutet

Host, The Conversation Weekly Podcast, The Conversation

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Underage Drinking: A Review of Trends and Prevention Strategies

Affiliations.

• 1 Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland.
• 2 Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism (NIAAA), Bethesda, Maryland.
• 3 The CDM Group, Inc., Bethesda, Maryland.
• 4 Alcohol Policy Consultations, Felton, California.
• 5 Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland. Electronic address: [email protected].
• PMID: 27476384
• DOI: 10.1016/j.amepre.2016.05.020

Underage drinking and its associated problems have profound negative consequences for underage drinkers themselves, their families, their communities, and society as a whole, and contribute to a wide range of costly health and social problems. There is increased risk of negative consequences with heavy episodic or binge drinking. Alcohol is a factor related to approximately 4,300 deaths among underage youths in the U.S. every year. Since the mid-1980s, the nation has launched aggressive underage drinking prevention efforts at the federal, state, and local levels, and national epidemiologic data suggest that these efforts are having positive effects. For example, since 1982, alcohol-related traffic deaths among youth aged 16-20 years have declined by 79%. Evidence-based or promising strategies for reducing underage drinking include those that limit the physical, social, and economic availability of alcohol to youth, make it illegal for drivers aged <21 years to drive after drinking, and provide mechanisms for early identification of problem drinkers. Strategies may be implemented through a comprehensive prevention approach including policies and their enforcement, public awareness and education, action by community coalitions, and early brief alcohol intervention and referral programs. This paper focuses on underage drinking laws and their enforcement because these constitute perhaps the most fundamental component of efforts to limit youth access to and use of alcohol.

Published by Elsevier Inc.

Publication types

• Research Support, Non-U.S. Gov't
• Research Support, U.S. Gov't, P.H.S.
• Accidents, Traffic / prevention & control
• Accidents, Traffic / trends*
• Age Factors
• Federal Government
• Law Enforcement
• Preventive Health Services / economics*
• Underage Drinking / legislation & jurisprudence*
• Underage Drinking / prevention & control*
• Underage Drinking / trends*
• United States
• Young Adult