Risk and protection: alcohol use among urban youth within the birth to twenty (BT20) cohort

Submitted in fulfilment of the requirements for the degree of DOCTOR OF PHILOSOPHY Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2015Background: South Africa (SA) faces a formidable threat to public health attributable to alcohol use. The heavy burden of alcohol-attributable morbidity, mortality and social harms borne by SA youth is concerning. In a series of papers, this study examined: current national trends in adolescent alcohol prevalence; the associations of prevalence with alcohol-related mortality; and the implications of the overall findings for alcohol policy in SA. The study also investigated adolescent alcohol use and its determinants at key developmental stages (early and late adolescence), among 1 647 urban adolescents in Soweto, South Africa. Employing a socio-ecological framework, multiple risk and protective factors that determine adolescent alcohol behaviours at late adolescence were empirically tested. Methods: Data originated from seven sources: two national household, (South Africa Demographic and Health Survey-SADHS); two school-based youth risk behaviours surveys (YRBS); and two phases of a mortuary-based sentinel surveillance study. Additionally, a cross-sectional survey of adolescent alcohol use and its determinants was nested within Birth to Twenty (Bt20), a birth cohort study which prospectively follows 3273 children and their mothers from its inception in 1990 to date. Following a review of national data among 13- 19 year olds, bivariate analysis of alcohol use and alcohol-related harm among 13- 19 year olds, and alcohol use and mortality among 15-19 year olds, respectively, pertinent policy implications are discussed. Descriptive statistical analyses examined alcohol prevalence at early (13 years) and late (17/18 years) adolescence in the Bt20 cohort, while bivariate and multivariate analyses determined the associations and predictive values of socio-demographic, individual, and interpersonal factors on adolescent alcohol behaviours. Multi-level generalised linear mixed modelling determined if community level variables explain variability in the likelihood of having engaged in alcohol behaviours at 17/18 years old. Results: Nationally, alcohol use was stable but high among adolescents at 20 - 25% (SADHS) and 49 - 50% (YRBS) over the period 1998-2008. Twelve percent of adolescents initiated alcohol use before age 13. Significant gender differences existed in alcohol consumption, with a predominance of male drinking. Binge drinking increased significantly among females from 1998 to 2003. Homicide, suicide and unintentional deaths among 15- 19 year olds were significantly* associated with positive blood alcohol concentration. Within the Bt20 cohort, lifetime and current alcohol use, and binge drinking, is prevalent, and increases with progression from early to late adolescence. Consistent with national findings, significantly* more males than females engaged in all alcohol behaviours. The frequency of lifetime alcohol use increased from 22% in early adolescence to 66% in late adolescence. Gender, maternal education, and socio-economic status (SES) predicted lifetime alcohol use in early adolescence, while marital status was an additional predictor of the same in late adolescence. In late adolescence, bivariate regression models indicated that alcohol refusal self-efficacy, alcohol expectations, peer influence, household SES, neighbourhood economic level and community level SES were significantly associated with lifetime alcohol use. However, multi-level analyses revealed no direct association between community SES and adolescent alcohol behaviours. Discussion: The high prevalence of lifetime, current alcohol use, and binge drinking, together with early alcohol debut indicates that, alcohol use is a significant public health problem facing SA youth. Adolescent drinking behaviour is the result of a complex interplay between individual, interpersonal and community-related risk and protective determinants. Empirically validated risk and protective factors represent potential points of intervention for prevention and reduction of adolescent drinking. This necessitates multi-faceted responses for prevention on one end of the continuum and harm reduction on the other. Conclusion: Findings challenge current regulatory alcohol policies, the implementation of which falls short of ensuring that minimum drinking age laws are adequately effected. In addition, regulatory policies appear inadequate in ensuring that strategies translate into a reduction in harmful alcohol use by SA youth. Authoritative and consistent implementation of regulatory policies, in addition to harm reduction strategies, is necessary. *p<0.0

Trends in alcohol prevalence, age of initiation and association with alcohol-related harm among South African youth: Implications for policy

Objectives. To understand alcohol use trends and alcohol-related harm among youth in South Africa (SA) between 1998 and 2008, and discuss implications for the current alcohol policy process.Methods. A review was conducted of 4 national prevalence and 2 sentinel surveillance studies. Data were extracted to Epi Info (version 7) and chi-square analyses undertaken.Results. Lifetime alcohol use remained stable but high at 20 - 25% and 49.1 - 49.6% according to South African Demographic and Health Survey (SADHS) and Youth Risk Behaviour Survey (YRBS) data, respectively. Age of initiation remained stable; 12% of adolescents initiated alcohol use prior to age 13 years. Significant gender differences existed with more males having ever consumed alcohol, engaged in binge drinking, and driven or walked under the influence of alcohol (DUI and WUI, respectively). Binge drinking among females increased significantly from 27% to 36% (SADHS) and 18% to 27% (YRBS). DUI and WUI increased. Homicide/violence, suicide and unintentional deaths were significantly associated with blood alcohol concentration (BAC).Conclusions. Although SA has made significant strides in alcohol control and prevention of alcohol-related harm over the past decade, early alcohol initiation remains a concern and binge drinking is increasing, especially among females. Significant associations exist between BAC and alcohol-related fatalities. Findings imply that regulatory policies are inadequate; additional efforts are required to ensure that control strategies translate into a reduction in harmful alcohol use by SA youth.S Afr Med J 2012;102(7):609-61

Trends in alcohol prevalence, age of initiation and association with alcohol-related harm among South African youth: Implications for policy

Objectives. To understand alcohol use trends and alcohol-related harm among youth in South Africa (SA) between 1998 and 2008, and discuss implications for the current alcohol policy process. Methods. A review was conducted of 4 national prevalence and 2 sentinel surveillance studies. Data were extracted to Epi Info (version 7) and chi-square analyses undertaken. Results. Lifetime alcohol use remained stable but high at 20 - 25% and 49.1 - 49.6% according to South African Demographic and Health Survey (SADHS) and Youth Risk Behaviour Survey (YRBS) data, respectively. Age of initiation remained stable; 12% of adolescents initiated alcohol use prior to age 13 years. Significant gender differences existed with more males having ever consumed alcohol, engaged in binge drinking, and driven or walked under the influence of alcohol (DUI and WUI, respectively). Binge drinking among females increased significantly from 27% to 36% (SADHS) and 18% to 27% (YRBS). DUI and WUI increased. Homicide/violence, suicide and unintentional deaths were significantly associated with blood alcohol concentration (BAC). Conclusions. Although SA has made significant strides in alcohol control and prevention of alcohol-related harm over the past decade, early alcohol initiation remains a concern and binge drinking is increasing, especially among females. Significant associations exist between BAC and alcohol-related fatalities. Findings imply that regulatory policies are inadequate; additional efforts are required to ensure that control strategies translate into a reduction in harmful alcohol use by SA youth

Addressing adolescent alcohol use in South Africa

Excessive alcohol consumption constitutes a significant public health problem for South Africans. Alcohol use by South African (SA)adolescents is characterised mainly by binge/heavy episodic drinking. Levels of binge drinking have been high, but relatively stable, amongmales since 2002, while there has been a significant increase in binge drinking by females since then. Binge drinking is a major risk factorfor a range of alcohol-related harms in SA, including traffic-related accidents and deaths, interpersonal violence, fetal alcohol spectrumdisorder (FASD), crime, sexual risk behaviour, HIV, tuberculosis and the resultant burden of all of these on the economy. Clinicians mayplay a key role in addressing adolescent alcohol use and alcohol-related harm. Such a role may involve screening, brief interventions andreferrals to treatment. There are several assessment, screening and diagnostic tools to detect alcohol use and misuse, specifically amongadolescents. Furthermore, various pharmacological and psychological approaches are available to treat adolescent alcohol problems. Specialissues to consider when dealing with alcohol use problems among adolescents in SA include recognising the risk factors, and acknowledgingand addressing the harms associated with alcohol use (including sexual risk behaviour and FASD) and the possible existence of comorbidmental health problems

Adolescent Health Series - alcohol, tobacco, and other drug use among adolescents in sub-Saharan Africa : A narrative review

Abstract: Alcohol, tobacco, and other drug (ATOD) use by adolescents are major contributors to death and disability in sub-Saharan Africa (SSA). This paper reviews the extent of adolescents’ ATOD use, risk and protective factors, and studies evaluating prevention interventions for adolescents in SSA. It also describes the harms associated with adolescents’ ATOD use in SSA, which mainly include interpersonal violence, sexual risk behaviours, and negative academic outcomes. We use the socio-ecological model as our framework for understanding ATOD use risk and protective factors at individual, interpersonal, peer/school, and societal/structural levels. We used two strategies to find literature evaluating ATOD interventions for adolescents in SSA: (a) we sought systematic reviews of adolescent ATOD interventions in SSA covering the period 2000–2020; and (b) we used a comprehensive evidence review strategy and searched for studies that had evaluated ATOD interventions in all SSA countries between 2000 and 2020. Only two community interventions (a brief intervention and an HIV prevention intervention), out of four that were identified, were partially effective in reducing adolescent ATOD. Furthermore, only one school-based intervention (HealthWise), out of the six that we uncovered, had any effect on ATOD use among adolescents. Possible reasons why many interventions were not effective include methodological limitations, involvement of non-evidence- based education-only approaches in some studies, and shortcomings in adaptations of evidence-based interventions. The scale of ATOD and related problems is disproportionate to the number of evaluated interventions to address them in SSA. More ATOD interventions need to be developed and evaluated in well-powered and well-designed studies

Alcohol use in early and late adolescence among the Birth to Twenty cohort in Soweto, South Africa

Background: Alcohol is a risk factor for the leading causes of mortality and morbidity among young people globally. Youth drinking, initiated in early adolescence and continued into early adulthood, is influenced by maternal socio-demographic factors and maternal education. Limited prospective data exists in South Africa on the prevalence of alcohol use during adolescence and adolescent and maternal socio-demographic correlates. Objective: To examine the prevalence of lifetime alcohol use during early (13 years) and late (18 years) adolescence in Soweto, South Africa, and its association with child and maternal socio-demographic factors. Methods: Data on alcohol use in early adolescence (age 13 years) and late adolescence (age 18 years) were collected using self-completed pen and paper and self-completed computer-based questionnaires, respectively. Univariate analyses were conducted on child (gender and number of school years repeated by grade 7), maternal socio-demographic correlates (education, marital status, and age), and household socioeconomic status (SES). Bivariate logistic regression analyses examined associations between alcohol use and all child and maternal socio-demographic factors. Multivariate logistic regression analyses were conducted on all the variables found to be significantly (pB0.10) associated with alcohol use to examine the predictive value on alcohol use at early and late adolescence. Results: Lifetime alcohol use increased from 22% at early adolescence to 66% at late adolescence. In multivariate analyses, gender, maternal education, and SES predicted lifetime alcohol use at early adolescence, while gender, maternal education, marital status, and SES were predictive of the same at late adolescence. Conclusion: This study aids researchers and practitioners to identify maternal and child socio-demographic risk profiles for alcohol use to inform policies and programmes

Risk factors for alcohol and drug misuse amongst young women in informal settlements in Durban, South Africa

Alcohol and drug misuse (ADM) pose a significant disease burden globally. Yet, there remains a gap in understanding risk factors associated with women’s ADM, particularly those in marginalised settings. We investigated risk factors associated with ADM amongst young women in urban informal settlements in South Africa. Bivariate and multivariable logistic regression analyses were conducted on a sample of 680 young women assessing associations between sociodemographic factors, mental health, relationship factors and past year ADM. Alcohol misuse was assessed using the 10 item Alcohol Use Disorders Identification Test (AUDIT) scale, with scores ≥8 defining misuse, a single item assessed past year illegal drug use. Alcohol and drug misuse were reported by 23.1% and 31.8% of the women respectively. In multivariable regression, alcohol misuse was associated with experiencing past year non-partner sexual violence, transactional sex with a main partner, past year drug use, and past week depressive symptoms, while drug misuse was associated with alcohol misuse, transactional sex with a casual partner, past year experience of physical and/or sexual IPV and having a functional limitation (disability). Results indicate ADM in informal settlements are shaped by violence and poor mental health. Interventions geared towards strengthening women’s economic position and mental healthcare are recommended

New learnings on drivers of men’s physical and/or sexual violence against their female partners, and women’s experiences of this, and the implications for prevention interventions

Background: Understanding the drivers of intimate partner violence (IPV), perpetrated by men and experienced by women, is a critical task for developing effective prevention programmes. Objectives: To provide a comprehensive assessment of the drivers of IPV. Methods: A comprehensive review of the drivers of IPV, at the end of a six-year programme of research through the What Works to Prevent Violence Against Women and Girls Global Programme with reference to other important research in the field. Results: Broadly, we argue that IPV is driven by poverty, patriarchal privilege, and the normative use of violence in interpersonal relationships. These factors also increase childhood trauma, poor mental health and substance misuse, and poor communication and conflict in relationships, which in turn impact on IPV. Disability status, and contexts of armed conflict, or post-conflict, further reinforce and exacerbate these risks. We move beyond describing associations towards describing the causal pathways through which these factors operate to increase IPV. Conclusions: Specific recommendations about the future of further research on drivers of IPV include a greater focus on understanding the causal pathways from drivers to IPV and clearly delineating association from causality in studies, particularly for women and girls with disabilities, in armed conflicts, and adolescent girls and young women. To achieve this, we recommend extensive in-depth qualitative research, and complex quantitative modeling studies. Understanding drivers and causal pathways better will enable the identification of points of entry for the development of more effective IPV prevention interventions

Can alcohol policy prevent harms to women and children from men's alcohol consumption? An overview of existing literature and suggested ways forward

The World Health Organization's list of cost-effective alcohol control policies is a widely-used resource that highlights strategies to address alcohol-related harms. However, there is more evidence on how recommended policies impact harms to people who drink alcohol—such as physical health problems caused by heavy alcohol use—than on secondhand harms inflicted on someone other than the person drinking alcohol, i.e., alcohol's harms to others. In this essay, we describe evidence of impacts of alcohol policy on harms to women and children resulting from men's alcohol consumption, as well as options for making policies more relevant for reducing intimate partner violence and child abuse. We begin with an overview of harms to women and children resulting from men's alcohol consumption and review cost-effective alcohol policies with potential to reduce these harms based on likely mechanisms of action. Next, we present a rapid review of reviews to describe existing evidence of impacts of these policies on the outcomes of physical violence, sexual violence, and child abuse and neglect. We found little evidence of systematic evaluation of impacts of these important alcohol policies on harms to women and children. Thus, we advocate for increased attention in evaluation research to the impacts of alcohol policies on harms experienced by women and children who are exposed to men who drink alcohol. We also argue for more consideration of a broader range of policies and interventions to reduce these specific types of harm. Finally, we present a conceptual model illustrating how alcohol policies may be supplemented with other interventions specifically tailored to reduce alcohol-related harms commonly experienced by women and children as a result of men's alcohol use.The US National Institute on Alcohol Abuse and Alcoholism (NIAAA) at the National Institutes of Health (NIH), the Gender and Health Research Unit, South African Medical Research Council, the Australian Research Council, Victorian Health and Medical Research Workforce Project under auspices of the Victorian Government and the Association of Australian Medical Research Institutes with funding provided by the Victorian Department of Jobs, Precincts and Regions), and the National Health and Medical Research Council. The collaborative initiative was funded by the International Health Policy Program, Thai Ministry of Health as part of an ongoing WHO–Thai Health Promotion Foundation collaboration for strengthening networks and technical capacity for alcohol policy development.http://www.elsevier.com/locate/drugpo2024-08-02hj2023School of Health Systems and Public Health (SHSPH)SDG-05:Gender equalit