Alcohol use and abuse among rural Zimbabwean adults: A test of a community-level intervention
Introduction
Understanding what factors contribute to alcohol misuse is important given its health consequences, and this is especially so in societies with few resources to address the harmful effects of alcohol abuse (Obot, 2006), including its links to high-risk sexual behaviors and HIV. Hahn et al. (2011) have noted that there is a lack of longitudinal studies specifically addressing alcohol consumption among those at risk for or already infected with HIV in sub-Saharan Africa (SSA; Hahn et al., 2011). The present study seeks to fill this gap by investigating alcohol use and abuse in rural Zimbabwe over a two-year period and testing the impact of a community-level intervention in reducing alcohol misuse.
Although there is limited information on alcohol use in Zimbabwe and other parts of SSA, statistics reported by the World Health Organization (2011) indicate a high level of lifetime abstinence among men (58.1%) and women (91.6%) in Zimbabwe. Average per capita consumption between 2003 and 2005 was 5.1 liters among Zimbabweans 15 years or older, of which approximately 20% was non-standard or unrecorded alcohol consumption (e.g., consumption of homemade or informally produced alcohol whether legal or illegal, smuggled alcohol, alcohol intended for industrial or medical uses, alcohol obtained through cross-border shopping; Obot, 2006, WHO, 2004, WHO, 2011). Among drinkers 15 years or older, 39% of men and 20% of women were heavy episodic drinkers (i.e., drank at least 60 grams or more of pure alcohol at least once per week). In addition, the average (2003–2005) per capita liters of alcohol consumed by drinkers in Zimbabwe was 35.3 (World Health Organization, 2011). Although alcohol is often used in ceremonies and rituals, it is primarily consumed in commercial social contexts (e.g., bottle stores, beer halls; Garbus and Khumalo-Sakutukwa, 2003) with men being more likely than women to drink in beer halls or bottle stores. The current research provides additional information on what factors contribute to alcohol use and abuse in rural Zimbabwe and on the effectiveness of an intervention aimed partly at reducing alcohol abuse.
Past research has shown that both individual and community factors are related to alcohol consumption. For example, age, gender, marital status, socioeconomic status (SES), and religious and other cultural influences have each been linked to levels of alcohol use (e.g., Adelekan et al., 1993, Hahn et al., 2011, Hargreaves, 2002, Luczak et al., 2002). Peers also can have strong effects on substance use (Camlin and Snow, 2008, Mbizvo et al., 1995, Ndlovu and Sihlangu, 1992), suggesting that the social environment may be an effective intervention target for reducing alcohol abuse across a population.
Some community-level interventions that draw on peer influences have been found to be effective in changing a community's social norms and cultural environment regarding risk-taking behaviors (e.g., Rogers, 1995, Rogers and Kincaid, 1981). Based on the theory of diffusion of innovations (Kelly et al., 1991, Kelly et al., 1992a, Kelly et al., 1992b), the Community Popular Opinion Leader (CPOL) intervention uses popular individuals or opinion leaders in a community to spread culturally specific health-related messages to their friends and neighbors through casual conversations delivered in their own words (Kelly, 1999, Kelly et al., 1997, St. Lawrence et al., 1994). The intervention is targeted at the individual level but is expected to diffuse throughout a community via word of mouth and social normative influence. The relative low cost and low technology of this intervention (Kelly, 1999, Pinkerton et al., 1998, St. Lawrence et al., 1994), as well as the ease in implementing the intervention, makes it particularly suitable for rural areas in Zimbabwe where resources are often scarce.
The current study was an addition to an NIMH AIDS Collaborative Trial involving a two-armed randomized, controlled trial of a CPOL intervention designed to decrease STD rates by addressing sexual and other risk behaviors, including alcohol abuse. The target population was adults (ages 18–30) in rural communities in Zimbabwe who were followed over a two-year period. The trial offered an opportunity to evaluate the impact on alcohol use in rural Zimbabwe of a CPOL intervention that conveyed the message of not drinking alcohol excessively. In this study, we address three research questions. First, what is the impact of socio-demographic, cultural, and provincial characteristics on adult alcohol use in rural Zimbabwe? Second, how effective is the CPOL intervention in reducing alcohol abuse in rural Zimbabwe? And, third, given that peers may have a larger impact on males than females (e.g., Lundborg, 2006), does the intervention effect vary by gender?
Section snippets
Intervention
For the study, thirty rural communities were selected from a set of communities designated as growth points (GPs) for economic development by the Zimbabwe state. The thirty GPs were selected for size, population stability, and minimum number (at least 5) of social venues, such as bottle stores and general dealers. Sample communities were paired based on geographic proximity and then randomly assigned to either the intervention or control group. The selected sample communities tended to have
Community-level tests
Our first step in testing the effectiveness of the CPOL intervention in rural Zimbabwe was to see whether the expected greater community-level declines in alcohol use in the intervention versus control communities occurred over the course of the study. To do this, we conducted paired-sample difference t-tests between the matched intervention and control sites, comparing the matched sites in terms of the level and direction of change in alcohol use behaviors across the waves (wave 1 versus waves
Discussion
This study addressed three research questions regarding alcohol use and abuse in rural Zimbabwe. First, we addressed what are the key factors affecting alcohol use in rural Zimbabwe and found that the factors with significant effects were similar to those in other countries. Higher drinking (e.g., any use, more frequent use, and/or greater quantities consumed) was generally associated with higher status (education), being male, older, or not married, or having no religious affiliation. Unique
Role of funding source
Funding for this study was provided by NIAAA Grant No. R21 AA014376. The NIAAA had no further role in: study design; in the collection, analysis and interpretation of data; in the writing of the report; or, in the decision to submit the paper for publication.
Contributors
Cubbins, Kasprzyk, Montano, and Woelk designed the study and wrote the protocol. Cubbins and Jordan managed the literature searches and summaries of previous related work. Kasprzyk, Montano, and Woelk managed the data collection and intervention. Cubbins and Jordan prepared the data, and Cubbins carried out the analysis and the preparation of the final draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
No conflict declared.
Acknowledgments
The contents are solely the responsibility of the authors and do not necessarily represent the official views of NIAAA, NIH, Battelle Memorial Institute, the University of Southampton, or the Elizabeth Glaser Pediatric AIDS Foundation. An earlier version of this paper was presented at the August 2009 annual meeting of the American Sociological Association in San Francisco, CA. The authors thank Claire Garabedian and Melanie Gallant for their assistance in data preparation.
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