Alcohol , Drug Use , and Sexual-risk Behaviors among Adolescents in Four Sub-Saharan African Countries

Rationale and Objectives The past two decades has witnessed a proliferation of empirical research on adolescent problem behaviors, including alcohol and drug use and unsafe sexual practice (e.g. Biglan et al., 1990; Newcom & Bentler, 1988; Santelli et al., 2001). A number of environmental, family, and individual factors have been associated with a range of adolescent risky behaviors. For example, adolescent who report a positive relationship with their mothers are less likely to be sexually active (Black et al., 1997; Miller et al., 2000) and have fewer partners (Miller et al., 1999) than their counterparts who report a negative relationship. Adolescents that are regularly supervised (monitored) by their parents have been found to be les likely to engage in sexual activity have fewer sexual partners, and more likely to use condoms than their counterparts with little or no parental supervision (Jacobson & Crockett, 2000). At the individual level, low alcohol use and low involvement in deviant activities such as fighting and getting suspended from school were associated with lower frequency of sexual intercourse (Miller et al., 2000). Having multiple sexual partners has also been associated with both ever-use and current use of alcohol or other substances and the more different substances that sexually active teens and young adults have ever tried, the less likely they are to have used a condom the last time they had sex (Santelli et al., 2001). The association between adolescent substance use and irresponsible sexual activity that increases susceptibility to HIV infection is also well established (DiClemente, 1990; Santelli et al., 2001; Graves, 1995; Mott & Haurin, 1988) and prior substance use has been shown to increase the probability of an adolescent initiating sexual activity (Mott et al., 1996). In sub-Saharan Africa, regular alcohol and drug use among adolescents is still relatively uncommon, such that substance use is often associated with higher socioeconomic status and urbanization (UNIDCP, 1997). However, gender differences in adolescent alcohol and drug use have been shown to be very pronounced, with boys being more likely to have experimented with and used substances than girls. For example, adolescent males in the urban informal settlements of Nairobi, Kenya are more than 20 times as likely to have ever used drugs, and 5 times as likely to consume alcohol as their female counterparts (Mugisha et al., 2003). Contextual factors such as living in urban areas, shortage of jobs, and school-age girls dating older men have also been proposed as important determinants of adolescent sexual behavior in Ethiopia (Eshete et al., 1993). The combination of these risk factors has been noted as critical in fueling the high incidence of HIV/AIDS among adolescents in the region (Asiimwe-Okiror et al., 1997; Malamba et al., 1994; Serwadda et al., 1992). Using a unique set of data collected in 2004 from nationally-representative surveys of adolescents, this study will examine protective and risk factors associated with alcohol, substance use, and risky sexual behaviors among 12-19 year olds in four countries in subSaharan Africa. It explores the nature and extent of alcohol, substance use, and risky sexual behaviors among adolescents in Burkina Faso, Ghana, Malawi, and Uganda. The specific objectives are to examine the sequencing of initiation of alcohol, drug use, and risky-sexual behaviors and how these vary by gender and to identify protective and risk factors associated with initiation of alcohol, drug use, and risky sexual behaviors. Data Source and Methodology Four nationally representative household-based surveys of 12-19 years olds were conducted in 2004 in Burkina Faso, Ghana, Malawi and Uganda. Survey questionnaires were designed to be similar in content and structure across the countries. The questionnaires were translated (and back-translated) into major local languages and pretested. Data collection was completed in June 2004 for Ghana and Uganda and August 2004 for Malawi and Burkina Faso. The surveys were implemented by Macro International, the same group that conducts many nationally representative household surveys in the developing world such as the Demographic and Health Surveys (DHS). Field logistics, sampling, and data quality checks were similar to those normally used in DHS surveys. The final survey samples were 5,955 in Burkina Faso; 4,410 in Ghana; 5,112 in Uganda; and 3,800 adolescents in Malawi. Preliminary Findings About one third (33%) of the adolescents in Burkina Faso and Uganda have tried alcohol compared to 23 % in Ghana and 18% in Malawi. Among adolescents who reported having tried alcohol in each of the four countries, about a third reported been drunk in the last 12 months except in Burkina Faso where only 14% reported being drunk in the last 12 months. Only 1-2% of the adolescents in the four countries reported having tried any other type of substance aside from alcohol. In all four countries, adolescents that reported a drunken episode in the last 12 months tend to have more than one sexual partner compared to their counterparts without a drunken episode. Among sexually experienced adolescents that had a drunken episode in the last 12 months in the four countries, Burkina Faso has the highest proportion (11%) who reported having multiple sexual partners in the last three months compared to 9% in Malawi, 8% in Ghana, and 6% in Uganda. Although the mean age of first sexual intercourse was comparatively similar across the countries (about 15 years), less than half of female adolescents aged 12-14 and 15-19 years have had sexual intercourse. Among male adolescents, Burkina Faso had a comparatively higher proportion of adolescents that were sexually experienced at ages 12-14. More than half (53%) of these boys reported they have ever had sexual intercourse in Burkina Faso compared to 20%, 15%, and 11% in Malawi, Uganda, and Ghana respectively. However, among adolescent males aged 15-19 years, Malawi had the highest proportion (59%) who reported they have ever had sex compared to 49% in Uganda, 33% (Burkina Faso), and Ghana (15%). Preliminary results also show that use of alcohol and other substances are associated with risky sexual behaviors and especially with multiple sexual partnerships and limited use of condoms. In this study, more than half of sexually active adolescents who use any form of substances reported not using condoms during their last sexual intercourse compared to their counterparts with no alcohol or drug use experience. Among sexually active adolescents that have ever drank alcohol in Malawi, about 68% reported not using condoms during their last sexual intercourse with a most recent partner compared to 65% in Uganda, 60% (Burkina Faso), and Ghana(58%). Similarly, among those adolescents that have ever used another mood altering substance (drug), about three-fourths (74%) in Malawi reported not using a condom during their last sexual intercourse with their most recent partner compared to 67% in Burkina Faso, 61% (Uganda) and Ghana (51%). Policy Implications The rapid economic, social, and cultural transitions that most countries in subSaharan Africa are now experiencing have created a breeding ground for increased and socially disruptive use of alcohol and drugs. Given the high prevalence of HIV/AIDS in the region and the increasing number of adolescents infected with HIV, an understanding of the role substance use plays in the spread of HIV/AIDS is crucial to prevention efforts of the disease among this population. Reliable knowledge on those factors that may predispose or diminish the risk of HIV among adolescents is crucial in the implementation of culturally relevant intervention strategies in the region. Evidence of the associations of protective and risk factors of alcohol, drug use, and risky sexual behavior among adolescents in sub-Saharan Africa will be useful to policy makers, program managers, and service providers in the design and implementation of policies and programs that specifically target this population.