literature review on drug abuse in schools in south africa

• Open access
• Published: 27 May 2024

Trends in socio-demographic characteristics and substance use among high school learners in a selected district in Limpopo Province, South Africa

• Linda Shuro 1 &
• Firdouza Waggie 2  

BMC Public Health volume  24 , Article number:  1407 ( 2024 ) Cite this article

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Substance use is an escalating public health problem in South Africa resulting in risky behaviours and poor educational attainment among adolescents. There is a huge battle to overcome substance use among learners as more drugs become easily available with the mean age of drug experimentation reported to be at 12 years of age. It is important to continuously understand the trends in substance use in order to assess if there are positive changes and provide evidence for the development of context-specific effective interventions. This paper outlines the prevalence of substance use among selected high schools in a district in Limpopo province.

To determine the prevalence of substance use among selected high school learners in a district in Limpopo Province, a cross-sectional school survey of 768 learners was conducted. Data was analysed using SPSS v 26. Descriptive analysis was used to describe the independent and dependent variables and Chi-Square test was used to investigate associations between demographic characteristics and substance use among high school learners.

The most abused substances by learners were alcohol (49%), cigarettes (20.8%) and marijuana (dagga/cannabis) (16.8%). In a lifetime, there was a significant difference ( P  < 0.05) in cigarette smoking with gender, school, and grade; with more use in males (14.2%) than females (7.6%); in urban schools (14.6) than peri-urban (6.7%) and more in Grade 12 (6.4%). There was a significant difference ( P  < 0.05) in alcohol use with more use in Grade 10 (12.6%) and varied use among male and female learners but cumulatively more alcohol use in females (27.7%). Drug use varied, with an overall high drug use in urban schools (20.7%).

Conclusions

Substance use is rife among high school learners in the district and health promotion initiatives need to be tailored within the context of socio-demographic characteristics of learners including the multiple levels of influence such as peer pressure, poverty, unemployment and child headed families. Additional research is required to investigate the factors leading to a notable gradual increase in use among female learners and into the environmental and family settings of learners in influencing substance use.

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Substance use and abuse is a major public health concern among female and male adolescents with prevalence varying in different contexts. Drug consumption in South Africa is twice the global average [ 1 ]. South Africa is ranked in the top 10 narcotics and alcohol abusers in the world. For every 100 people, 15 have a drug problem and for every 100 Rands in circulation, 25 Rands is linked to substance use [ 2 ]. Many schools in South Africa continue to battle with the problem of substance use among learners. The most experimented substances by adolescents in South Africa is tobacco and alcohol [ 3 ]. A majority of these adolescents are found in schools. The use of substances at an early age, especially among learners results in negative health and social outcomes such as school dropouts, and early onset of sexual behavior which may lead to teenage pregnancy and sexually transmitted infections [ 4 , 5 ]. A review of studies on impact of substance use on school performance and public health indicate that use of substances is significantly associated with negative school outcomes such as truancy, low motivation to learn, regular sickness, increasing school abstenteeism, decreasing marks and high chances of skipping school [ 6 , 7 , 8 ].

The mean age of drug experimentation in South Africa is 12 years and this is rapidly decreasing [ 9 ]. Globally 1 in 4 learners (13–15 years old) had their first smoke before the age of 10 and the percentage of use is greater than 10% for any tobacco product by 13-15-year-old learners [ 10 ]. The increased availability and variety of drugs available to South African teenagers is a cause for alarm, for example, marijuana (known as dagga/cannabis), cocaine, glue, methamphetamine known as TIK and whoonga known as “nyaope”-a street name for a mixture of mainly dagga and low-grade heroin [ 11 ]. South Africa is also experiencing an up rise in drugs and gangsterism labelled the “twin evils of our time”, especially found among youth in previously marginalized communities. The problem is viewed as an indication of the many socio-economic challenges faced by working class communities [ 12 ].

Global initiatives such as the WHO Global School Health initiative promote health promoting schools (HPS) to improve the health of the school community. An HPS is a “school constantly strengthening its capacity as a healthy setting for living, learning and working” [ 13 ]. The HPS approach was implemented in South Africa in 1994 in efforts to redress inequalities created during apartheid in the education and health sector and also the policy context was favourable for its acceptance [ 14 ]. There are many public health initiatives to address health issues among adolescents in South Africa which are integrated as part of the current health reforms such as re-engineering primary health care, National Drug Master Plan 2013–2017 [ 15 ] and the revised Integrated School Health Policy (ISHP). With a focus on school health, the ISHP was launched in 2012, as a collaboration between the Department of Health (DoH) and the Department of Basic Education (DBE) [ 16 ] as a framework for the new school health programme (grade 0 to 12 learners), implemented at sub-district level. It is therefore invested at the primary level and aligned to several government commitments such as the United Nations Convention on the Rights of the Child and Bill of Rights of the South African Constitution [ 17 ]. The above initiatives require a more integrated approach for effective change and to address the social determinants of substance use among learners [ 18 ].

Schools in Limpopo face multiple social challenges that affect effective teaching and learning such as crime and violence, sexual assault/abuse, substance use and bullying [ 19 ]. There was a recent outcry for action by learners to the Education Member of Executive Council (MEC) to address these social challenges [ 20 ]. A review of prevalence studies [ 21 , 22 , 23 , 24 , 25 ] in Limpopo high schools shows that male learners abuse drugs more than female learners. The review also showed past month low prevalence rates in rural high schools but with progression of studies and lifetime use, a gradual increase in prevalence rates in schools was noted. Some of the contributing factors to substance use noted include more access to finances by the males, the presence of liquor stores near the learners’ homes; certain demographic characteristics such as being male, urban versus rural learners; substance use among parents and friends. The major determinants of alcohol use found in students include, “gender, age, ever having smoked a cigarette, ever damaged property, walking home alone at night, easy availability of alcohol, thinking alcohol use was wrong, attending religious services and number of friends who used alcohol” [ 21 ]. A similar study identified the following five community level factors linked to use of home prepared alcohol by learners: i) subjective adult norms around substance use in the community, ii) negative opinions about one’s neighbourhood, iii) perceived levels of adult antisocial behavior in the community, iv) community affirmations of adolescents, and v) perceived levels of crime and violence in the community (derelict neighbourhood)” [ 26 ]. In one district in Limpopo, learners identified alcohol, tobacco, marijuana, petrol, glue and jeyes fluid mixed with spirit as the commonly used substances and other learners experimented on heroin and cannabis as they had friends with access to the drugs in town [ 27 ] which is consistent with other studies [ 28 , 29 ]. Youth in Limpopo are engaged in different substances (tobacco, alcohol, hard core drugs) with cannabis, inhalants, bottled wine, home, and commercially brewed beer as commonly abused substances [ 30 ]. This highlights the need for more monitoring studies to review the escalating situation of substance use among learners to create a wider data baseline for evidence-based initiatives. One of the research sessions at the 47th annual meeting of the Society for Epidemiologic Research on to tobacco and smoking showed that continued publication of health effects leads to reduction in smoking [ 31 ].

This study adds on to recent prevalence studies on substance use in high schools and adolescents in Limpopo province. Additionally, it contributes to baseline information which assists in the development of evidence-based initiatives. In line with the aims of international surveys [ 32 ] from which this study adopts, the findings support reporting of comparable data on drug use trends in Limpopo as well as having data from 1 of the 6 districts helps comparison within the province and supports targeted intervention and not a one size fits all approach. The main researcher was involved in anti-substance use clubs in some schools in Limpopo as part of health promotion and in light of many existing policies, it is worrying to note a gradual increase in prevalence rates of substance use amongst learners noting the gap between what is on paper and actual implementation (Lenkokile, 2016; Madikane, 2018; Mokwena et al., 2020). This study was an important process in Limpopo focused at providing current evidence towards developing effective context specific anti-substance use initiatives in high schools. The aim of this study was therefore to determine the prevalence of substance use among selected high school learners in schools in one district in Limpopo Province.

Study design

A cross-sectional survey (quantitative) was conducted among 768 high school learners from four high schools in the district.

Study population and sampling

The study population was all high school learners (N-13 244) enrolled in the period 2019–2020, Grade 8 to 12 [ 33 ]. Fifteen high schools within the Polokwane circuit were stratified into two strata according to socioeconomic and geographical divide: Urban and Peri-Urban. Simple random sampling was used to select two schools from each stratum. Once the four schools were identified, simple random sampling was used to select one class each from Grade 8 to 12 for participation in the cross-sectional survey. Consideration was taken to include the whole class so that learners are treated equally and excluding some students could affect anonymity perceptions and lead to disturbances [ 32 ]. However, due to the pressure of the announcement of the lockdown due to Covid 19 in March 2020 and schools closing, random sampling of classes was a bit limited to available classes in each grade.

Research sites

The study took place in four public high schools in the Polokwane circuit, Capricorn district, Polokwane local Municipality. The two peri urban schools selected are in the Seshego cluster on the north-west outskirts of the Polokwane city which is divided into 8 residential zones. Seshego is diverse with both extremes (poverty and wealth) located about 5kms from the CBD and most people must commute to the city for work. The urban schools are found more adjacent to the Polokwane city in Nirvana and Flora Park (formerly “coloured” and white” suburbs) but now quite diverse [ 34 ]. Polokwane is found in the Limpopo Province, South Africa. Limpopo is a rural province with 5 district municipalities: Capricorn, Sekhukhune, Waterberg, Vhembe, and Mopani. Within the Capricorn district are four local municipalities: Polokwane, Blouberg, Molemole and Lepelle-Nkumpi [ 35 ].

Data Collection

The school management and the heads of department for Life Orientation were instrumental to grant permission to conduct the survey and to randomly select one class per each grade to participate in the schools. The questionnaire was distributed to the learners to fill in and the researcher was present to explain the purpose of the research and address any clarifications. The survey took place in March 2020, a few weeks, and days before the national lockdown due to COVID 19. The self-administered questionnaire used in this study, is a modified instrument adapted from the UNODC Global Assessment Programme on Drug Abuse (GAP) Toolkit questionnaire on Conducting School Surveys on Drug Abuse. This tool is deemed valid and reliable as it was used and adapted in previous studies [ 36 , 37 , 38 ]. The original questionnaire was developed to build local level capacity among member states to collect data that can guide reduction activities in schools and therefore better fits the purpose for this study. The questionnaire was adapted to the local context using SA based terms and removing terms not relevant to the local context. A pilot study was conducted in a different circuit and adjustments made to the questionnaire and the process of data collection.

Ethical considerations

Permission to conduct the study was granted by the Limpopo Department of Education (Ref: 2/2/2) and the University of Western Cape (HS19/9/12). Information sheets, consent, and assent forms to participate in the study and seek permission from a guardian or parent were given to the learners prior to the data collection date. The researcher went with the invitations, information sheets and consent forms to the education circuit and these were sent to each school via the circuit office. The researcher also went with copies of the information sheets for the parents and learners to each school before the data collection. Therefore, the learners were informed of the study by providing them with an information sheet and explaining the purpose of the research and what is expected of them. An information sheet was also provided for the parents or guardians. Parents received information sheets and parental consent sought for learners to participate in the school survey. The signed forms from the parents/guardians were collected before administering the questionnaire to learners. Before administering the questionnaire, an explanation was provided again and learners above 18 received the consent forms and assent forms for learners under 18 to agree to participate in the study once they fully understood the purpose of the research.

Data analysis

Microsoft Excel was used to capture the data and exported to IBM SPSS v 26 for analysis to obtain baseline information about substance use in high schools (Briggs, 2016). Descriptive analysis was used to describe the independent and dependent variables using percentages, means, and standard deviation and inferential analysis such as correlation between sociodemographic characteristics and substance use, was used as well [ 39 ]. Percentages of gender, age, school, grades, level of parent’s education and person living with the learner were described. The frequency of substance use (alcohol, cigarette smoking and drugs) was presented to show lifetime, during the last 12 months and past 30 days (previous month) substance use. The Chi-Square test was used to investigate associations between demographic characteristics and substance use (cigarette smoking, alcohol use and drug use). The different p-values of less than 0.05 at a 5% significance level obtained, suggested that either grade, school, and gender have an influence and the differences on substance use depending on the substance. Percentages on awareness of substances, disapproval of substance use, friends who used substances, access to substances, perceived risk and associated behaviours under influence of substance use.

Demographic characteristics

Seven hundred and sixty-eight ( N  = 768) learners from four high schools participated in the survey. 54.2% ( n  = 416) were female and 45.8% ( n  = 352) male learners, with a mean average age of 16 years. There were 286 participants from two schools in the peri-urban (school 2 and 3) and 482 participants from the urban environment (school 1 and 4). The percentage of grades was distributed proportionally with a slightly increased percentage among the Grade 10s. The break-down of the participants is represented in Table  1 . The percentage of participation in each grade in each school varied due to class size variation. For purpose of this article, only geographical location (urban and peri-urban), gender, age and school are reported in relation to substance use.

Perceived availability and awareness of substances

In the four participating schools, learners responded to availability of several substances with cigarettes indicated as the most easily accessible substance 46.5% ( n  = 357) and mandrax the least accessible (see Table  2 ). The results indicate a wide variety of substances available to learners.

When learners were asked if they ever heard of the drugs listed on the questionnaire, learners had mostly heard of marijuana 72.1% ( n  = 554), nyaope 69.8% ( n  = 536), and least heard of ecstasy 22.3% ( n  = 171) and other drugs 22.5% ( n  = 173). Learners went on to mention the other drugs which included petrol, vape, tretamines and names that seemed mostly to be street names such as weed, Bluetooth, globe, flakka, hubbly, hashishka, cat, lollipop, ice pace and soil pill.

Trends in cigarette smoking and alcohol use

The overall lifetime prevalence of cigarette smoking among the learners was 20.8% (split according to the number of occasions (from 1 to 2 times to 40+) as seen in Table  3 ). 11.4% of the learners responded to have smoked during the last 12 months. In the last 30 days there was an overall prevalence of 7.1% further broken down by number of occasions. There was a high lifetime overall utilisation of alcohol with 49% of the learners having drunk alcohol (split according to the number of occasions (from 1 to 2 times to 40+) in Table  3 . 37.1% indicated alcohol consumption during the last 12 months with 13.7% who did not indicate. In the last 30 days the overall prevalence was at 20.9% with 16.3% who did not indicate. 9.6% of the learners indicated that they had five or more drinks in a row at least once and 4.4%, 10 or more times in the last 30 days.

An attempt was made to establish whether the learners’ socio-demographic characteristics were associated with cigarette smoking and alcohol use in a lifetime. The results as shown in Table  4 shows Chi-square test with a P- value of 0.000 at a 5% significance level suggesting that grade, school and gender have an influence on lifetime cigarette smoking. Schools in the urban area had an overall higher prevalence of cigarette smoking (14.6%) than schools in the Peri-Urban (7%) as cumulative effect. The results also show a significant difference in use for cigarette smoking by gender with more males (14.2%) than females (7.6%). The results in Table  4 also shows Chi-square test with a P- value of 0.001 for grade and 0.000 for gender suggest an association between lifetime alcohol use and these two socio-demographic characteristics with most alcohol use found to be in grade 10 (12.8%) and least in grade 8 (8%) as a cumulative effect. The differences in use among male and female learners varied with the number of occasions with overall high use in females (27.7%). There was no significant difference in alcohol use with schools.

Results showed that the age at first use of alcohol (beer, wine) and cigarette smoking was quite low at 13 years or less with a significant percentage even below 15 years of age. An age of 13 years or younger was taken as an indicator of early onset. At the age of 13 years or younger: 18.5% ( n  = 142) of the learners had drunk beer, 18.8% ( n  = 144) drank wine and 11.1% ( n  = 85) had smoked cigarettes. There was a percentage decline in use with increasing age.

Trends in drug use

Learners who tried drugs.

When asked if they had ever tried the listed drugs on the questionnaire, 19.3% male learners and 13.9% of the female learners said “Yes” to marijuana. The results for the other drugs had lower percentages which varied but indicate more males had tried out substances than females.

Lifetime use of drugs, during 12 months and last 30 days

Lifetime use of drugs varied with the type of drugs (see Fig.  1 ). A percentage overall of 16.8% of the learners had used marijuana in a lifetime, 13% in the last 12 months, and 8.4% in the last 30 days (see Fig.  1 ). Results also showed that the most common drug first tried was marijuana (dagga) (12.1%).

Drug use- Lifetime, During last 12 months and last 30 days

The Chi-square test was applied to investigate the association between socio-demographic characteristics and lifetime use of drugs. There was a significant association between school and the use of drugs prescribed by medical workers ( P  = 0.03), ecstasy (0.01), nyaope/whoonga (0.025) and mandrax (0.03) with higher use in urban (20.7%) compared to peri-urban (16.9%) schools. There was an association between grade and the use of marijuana (dagga) (0.000) with overall high use from Grade 10 to 12 and gender on the use of marijuana (0.000) and nyaope (0.018) with more males (25.1%) than females (14.1%).

Risk of substance use

46% ( n  = 352) of learners perceived great risk with smoking one or more packs of cigarettes per day, 40% ( n  = 307) perceived great risk by having four or five drinks in a row nearly every day, 24% ( n  = 183) of the learners perceived smoking cigarettes occasionally as a great risk but closely 22% ( n  = 169) perceived no risk with smoking occasionally, 19% ( n  = 147) no risk with having one or two drinks nearly every day and 16% ( n  = 125) no risk with trying marijuana.

This study investigated the prevalence of substance use among high school learners and highlighted how certain socio-demographic characteristics such as gender, grade, and school influence substance use patterns.

Notably, our findings reveal gender disparities in substance use. Whilst alcohol use varied with the number of occasions among female and male learners, there was an overall high alcohol use in females (27.7%) compared to their male counterparts (24.5%). It is essential to recognize that our study, primarily focused on prevalence, and did not delve into the determinants of substance use specifically within gender groups. Nonetheless, contextual factors such as poverty and gender-based violence prevalent in South African communities may contribute to the elevated substance use rates observed among female learners. Additionally, delays in accessing social assistance could potentially exacerbate risky behaviors among this demographic. Additional research is needed into factors influencing a gradual increase in uptake among female learners which was beyond the scope of this study.

The study also shows further gender disparity with male learners demonstrating higher levels of experimentation and use of drugs, particularly marijuana and nyaope (whoonga). This trend aligns with existing research, which consistently indicates a higher prevalence of substance abuse among male learners. A review of past and present prevalence studies conducted in Limpopo high schools corroborates this observation, with multiple studies consistently reporting higher rates of drug abuse among male learners [ 21 , 22 , 23 , 24 , 25 , 26 ]. Assumptions from observation can be made that this could be linked to societal settings and friends in which boys “hang out” with more than girls and may have ease of access to drugs. Males tend to be found more on the corners of streets, shops and stay out late. The phenomenon of having more male users than females is found in many prevalence studies [ 20 , 29 , 48 , 49 , 50 ] suggesting the need for male-oriented initiatives. To show the magnitude of the problem “Harmful use of alcohol is accountable for 7.1% and 2.2% of the global burden of disease for males and females respectively” [ 51 ]. However, several studies are beginning to show that there is little difference in use between genders [ 55 ]. This suggests the need for gender-specific initiatives to ensure effective programs among adolescents.

The results of the present study indicate that substance use is rife in both peri-urban and urban environments among high school learners in the district. In a lifetime, cigarette smoking (20.8%), alcohol (49%), and marijuana (16.8%) were identified as the commonly used substances among the learners, mirroring trends observed in past studies conducted in Limpopo and Sub-Saharan Africa. A baseline study among youth conducted in Limpopo in 2013 showed percentage use of inhalants at 39%, marijuana (49%) and alcohol (54,8%) as the most used substances [ 30 ]. Similarly, a systematic review of 27 studies in Sub-Saharan Africa among 143 201 adolescents shows that alcohol (32.8%), tobacco products (23.5%), khat (22%) and cannabis (15.9%) were the most commonly used substances [ 53 ].

Despite these similarities, the present study indicates a decrease in the percentage use of these substances compared to past studies. This discrepancy could potentially be attributed to the present study’s focus on selected high schools within a district, as opposed to previous studies that may have had broader sampling across the entire province or region. Nonetheless, overall this data is comparable to a certain extent to results of national surveys that have been conducted using a similar instrument which show trends in use in a lifetime, annually and in the past month and correlations across demographic characteristics and substance use. Examples include the annual drug national survey of 2020 (Monitoring the Future) in the United States [ 38 ] and an older survey in Kenya on patterns of drug use in public secondary schools [ 36 ]. Therefore, the findings add to a wider data baseline for evidence-based initiatives and more specific to Limpopo towards evidence-based context-specific anti-substance use initiatives in high schools.

A worrying phenomenon observed in this study and other previous studies is the decreasing age of onset of substance use at the age of 13 years or less. Despite the legal restrictions in South Africa setting the minimum age purchasing alcohol and cigarettes at 18, adolescents are gaining access to these substances, as indicated by the study findings. The findings are consistent with the study conducted in Limpopo in 2013, which shows the age of first use of cannabis/marijuana as early as 10 years or less [ 29 ]. There have been policy discussions to amend the age to 21 but this may seem not to be effective considering that alcohol is easy to access by a 13-year-old or younger suggesting a “ thriving illegal market” [ 40 ]. A similar finding by the Southern Africa Alcohol Policy Alliance (SAAPA) showed that 12% of those under 13 years were said to have drunk alcohol in the past month and 25% of young people binge drinking [ 40 ]. The rise in underage use may also be linked to the ongoing alcohol advertising which is prominent in the neighbourhoods and entices adolescents. With mixed views on the introduction of the new Limpopo tobacco bill, it’s crucial to monitor any changes in adolescent access to substances. Calls for the bill to enforce strict measures on the sale of tobacco products to minors highlight the urgency of addressing this issue [ 52 ].

According to the WHO Global status report on alcohol and health [ 41 ], Alcohol is the leading risk factor for premature mortality and disability among those aged 15 to 49 years, accounting for 10% of all deaths in this age group. This highlights a huge public health challenge and the need for preventive strategies that target lower grades before the onset of substance use. Whilst learners are aware of the different types of substances there is still a significant number of learners who do not perceive the risk of smoking and drinking occasionally and trying marijuana. To improve the perceived risk associated with substance use among learners, as part of integration in education, consistent awareness programmes in all the subjects of the curriculum could assist in improving the level of perceived risk and not limited to the Life Orientation subject in the school curriculum only as recommended that health education should be established in all school topics [ 42 ]. . This approach aligns with recommendations from the U.S. Department of Health & Human Services [ 56 ], which emphasize the significance of prevention programs at different life stages and involving the community.

The increased lifetime utilisation of alcohol, cigarettes, and marijuana is linked to the ease of access of these substances as first experimental substances, providing a gateway for the introduction of other substances [ 30 ]. In line with the ecological model on determinants of health, some of the multiple factors for increased use and availability of marijuana among the learners could be that South Africa is ranked among the countries in the region where cannabis cultivation and production occur to a large extent and marijuana use is legalised for adults to cultivate and smoke in their homes. A contributing factor to use by learners is substance use by parents or adults they live with. In 2017, 3.8% of the global population aged 15 to 64 years used cannabis at least once and cannabis use increased significantly between 2010 and 2017 in Africa [ 46 ]. Cannabis (marijuana/dagga) is highly used globally with approximately 3.8% between 15 and 64 years, about 188 million people having used it once or more times in 2017 (UNODC, 2019). Cannabis is ranked among the most used substances among adolescents attributed to its ease of access and a low and drop in the percentage of the perceived risk of using it, as evidenced in Western countries (UNODC, 2018; UNODC, 2014; UNODC, 2021).

In terms of geographical determinants of substance use and abuse, there were higher percentages of cigarette smoking and drug use in the urban schools compared to peri-urban schools. There is a diverse group of learners attending schools in urban areas coming from different areas including from the peri-urban and rural areas. The majority of the learners commute to attend schools and are exposed to access and use of substances when traveling which contributes as a factor to the ongoing public health concern of substance use among adolescents. This phenomenon of learners commuting long distances is also highlighted by a study in New York where older students, girls, and higher attaining students are likely to commute to distant schools despite schools close to them [ 54 ]. As a result, the road to school exposes learners to many risky situations including access to substances. A collaboration between the Department of Education and the Department of Transport should exist to ensure safe transport systems for learners whilst, at the same time, more work needs to go into improving local schools working together with the local municipality.

There is a need for policy coherence in all sectors to address substance use especially in the health, education, justice, transport, trade and social development sectors. Policies in the trade sectors which ensure strict adherence to the sale of substances, harsher sentences in the justice sector for the illegal market, improvement in quality of local schools and improved learner transport, if adequately implemented can curb the access and exposure of substances among minors. Key policies like the National Drug Master Plan, which aims for a drug-free society through collaboration with other national departments such as health, justice, and education, need strengthening and universal implementation, including in all schools [ 47 ]. While numerous health-oriented public policies exist, there’s a noticeable gap in their implementation, highlighting the necessity for increased resources allocated toward their effective execution [ 43 ].

The revised ISHP has a component on health education on prevention of substance use. If implemented in all schools, it has a potential to reach learners and raise awareness at an early age and across all phases (foundation, intermediate and senior) on the dangers of use and may contribute more effectively to the reduction of substance use and early onset [ 44 ]. The School Safety Programme which derives itself from many of the policies including the South African Constitution, School Health Promotion, and Children’s Justice Act should also be strengthened to assist in the prevention and control of drugs in schools. The programme has a component of building capacity among school stakeholders [ 45 ]. Training should be escalated to all including educators to assist with the timely identification and intervention of learners who use drugs. Parents or guardians need to be included in the training and implementation process for prevention to support behavior change among the learners.

Limitations

There are two major limitations in this study that could be addressed in future research. Firstly, the analysis was restricted to specific socio-demographic variables, overlooking the potential influence of parents’ educational attainment and the composition of the learners’ living environment. Due to constraints in resources and time, this study did not delve into the association between substance use and these factors. However, exploring the impact of parents’ level of education and the presence of individuals residing with the learners could offer a more comprehensive understanding of the underlying determinants of substance use. Future research endeavors should prioritize investigating these associations to enrich the existing knowledge base.

Secondly, the selection of classes was not randomized but based on availability, primarily due to logistical challenges exacerbated by the unforeseen onset of the Covid-19 pandemic and subsequent lockdown measures. Schools were compelled to adapt their operations swiftly, hindering the feasibility of a randomized sampling approach. Despite this limitation, the selected classes adequately represented the target population and facilitated the attainment of the study’s objectives. It is important to note that the deviation from randomization was a pragmatic adjustment necessitated by external circumstances and did not compromise the integrity or validity of the research findings.

Addressing these limitations in future studies will enhance the comprehensiveness of investigations into the complex dynamics of substance use among learners.

The findings of the study indicate that substance use is rife in high schools and utilization varies with sociodemographic characteristics. A more robust approach should be implemented which supports consistent health education integrated within all subjects of the curriculum from an early age. This should explore interactive means to reach the different social and educational platforms for learners to be informed, perceive the risk of substances from an early age and receive support. Findings also suggest the need for tailored health promotion programmes depending on the demographics of the learners (gender, grade and location of school) while also addressing the social determinants of substance use. One size does not fit all. The findings of this study contribute to the body of updated evidence on the prevalence of substance use in Limpopo Province among high school learners.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Central Drug Authority

Department of Basic Education

Department of Education

Department of Health

Department of Social Development

Department of Corporate Governance and Traditional Affairs

Human Immuno-deficiency Virus

Head of Department

Health Promoting Schools

Integrated School Health Policy

National School Safety Framework

Primary Health Care

South African Medical Research Council

South African National Council on Alcoholism and Drug Dependence SACENDU: South African Community Epidemiology Network on Drug Use

Statistics South Africa

School Governing Body

School Management Team

Crystal Methamphetamine

United Nations Office of Drugs and Crime

United Nations Population Fund

United Nations Children’s Fund

World Health Organisation

Youth Risk Behaviour Survey

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Acknowledgements

This work is based on the research supported by The Belgian Directorate- General for Development Cooperation, through its Framework Agreement with the Institute for Tropical Medicine (Grant Ref: FA4 DGD-ITM 2017–2020). The authors would also like to acknowledge funding from the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation of South Africa (grant no. 82769)’. Opinions expressed and conclusions arrived at, are those of the authors and are not necessarily to be attributed to the funders.

The Belgian Directorate- General for Development Cooperation, through its Framework Agreement with the Institute for Tropical Medicine (Grant Ref: FA4 DGD-ITM 2017–2020), The South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation of South Africa (grant no. 82769) funded the involvement of LS in this study.

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The research proposal for the study received ethical clearance from the University of Western Cape (UWC) Humanities and Social Sciences Research Ethics Committee from 18 November 2019 to 18 November 2020, ethics reference number: HS19/9/12. An application to the ethics committee for additional ethical amendments was made to include conducting interviews virtually in July 2020 due to the Covid-19 lockdown regulations. Ethics renewal was also sought and granted with an extension from 21 April 2021 to 21 April 2023. Permission was granted to conduct the study by the Limpopo Department of Education within the selected schools. The study was conducted in accordance with the general ethical guidelines and regulations of the ethics committee and Department of Education. Informed consent, anonymity, confidentiality and right to withdraw was assured to all the participants. Informed consent ensured that the participants were fully informed of what the study entailed, what is expected from them, for them to decide whether they will participate in the research or not. The researcher visited each of the schools and explained the study to the principals and HOD. The researcher also visited the NGO that participated to present the study and ask for participation. The researcher went with the invitations, information sheets and consent forms to the circuit and these were sent to each school via the circuit office. The researcher also went with copies of the information sheets for the parents and learners to each school before the data collection. Therefore, the learners were informed of the study by providing them with an information sheet explaining the purpose of the research and what is expected of them. They also received the consent forms and assent forms to agree to participate in the study once they fully understood the purpose of the research. Parents/legal guardians received information sheets and parental informed consent sought for learners to participate in the school survey. Anonymity was assured by the fact that participants’ information/responses were not ascribed to them specifically. It was assured that no names of individuals or the schools were written on the transcripts or in the report or publications. A preliminary report was made available to all relevant participants to verify the accuracy of the information before submission of the thesis for marking. An explanation was provided that the research is for academic purposes only and that there are no foreseeable risks from this research. Counselling and referral services to a social worker were arranged if participants experienced emotional discomfort during the data collection. However, during data collection, no participants required such services. Participants were informed that they are free to not participate further in the study at any time during the data collection process. It was explained that the research is not designed to help the participants personally, but the results may help the investigator learn more about factors linked to substance abuse in high schools and develop informed strategies. It was explained that the study provided valuable information and resources (Anti-Substance Abuse Initiative and situational analysis of the problem) which can benefit the high school community to develop skills to tackle substance abuse. This in turn could improve educational attainment and reduce risky behaviours.

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Shuro, L., Waggie, F. Trends in socio-demographic characteristics and substance use among high school learners in a selected district in Limpopo Province, South Africa. BMC Public Health 24 , 1407 (2024). https://doi.org/10.1186/s12889-024-18927-7

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• Substance use
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• Cross-sectional survey
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Prevalence and correlates of substance use among school-going adolescents (11-18years) in eight Sub-Saharan Africa countries

• Nuworza Kugbey   ORCID: orcid.org/0000-0002-0413-0350 1  

Substance Abuse Treatment, Prevention, and Policy volume  18 , Article number:  44 ( 2023 ) Cite this article

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Substance use constitutes a major public health issue especially among adolescents as it has associated adverse behavioural, health, social and economic outcomes. However, there is a paucity of comprehensive evidence on the prevalence and associated factors of substance use (alcohol, marijuana and amphetamine) among school-going adolescents in sub-Saharan Africa (SSA). This study examined the magnitude of substance use and its associated factors among school-going adolescents in eight eligible sub-Saharan Africa countries.

Data for the study were obtained from the Global School-based Health Survey (2012–2017) of 8 countries in SSA (N = 16,318).

Findings showed overall prevalence rates of 11.3% (95%CI = 10.8 − 11.8%), 2% (95%CI = 1.8 − 2.2%) and 2.6% (95%CI = 2.3 − 2.9%) for current alcohol use, current marijuana use and lifetime amphetamine use, respectively between 2012 and 2017. Late adolescence (15–18 years), being male, anxiety, bullying, fighting, truancy, having close friends, current cigarette smoking and tobacco use are significant risk factors for alcohol use. Anxiety, truancy, current cigarette smoking, tobacco use and suicidal attempt are significant risk factors for marijuana use. Anxiety, bullying, truancy, current cigarette smoking, tobacco use and suicidal attempt are significant risk factors for amphetamine use. Parental knowledge of activity, supervision and respect of privacy are significant protective factors of substance use.

There is the need for comprehensive public health policies beyond school-based psycho-behavioural interventions targeting the significant risk factors of substance use among school-going adolescents in SSA.

Introduction

Substance use among adolescents is a major public health issue as its consequences transcend physical health, psychological problems and social problems to include truancy and poor academic performance due to memory problems [ 1 , 2 , 3 , 4 ]. According to the WHO, the adolescence period is a transition between childhood and adulthood, usually from 10 to 19years. Some early researchers have categorized adolescents between 10 and 14years as early adolescence and those between 15 and 19years as late adolescence [ 5 ]. The Global Burden of Diseases (GBD) study reported alcohol use to be the 4th leading cause of disability among youth between 10 and 24years with significant sex variations [ 6 , 7 ]. Substance use among adolescents is associated with poor physical health outcomes, serious injuries, depression, anxiety, truancy, poor academic performance and other risky behaviours [ 1 , 4 , 5 , 8 , 9 , 10 , 11 ].

Estimates from individual studies on alcohol use among in-school adolescents in SSA countries range from 10 to 44% [ 10 , 12 , 13 , 14 ]. Apart from alcohol use, marijuana and amphetamine use are on the rise among adolescents with their associated negative consequences. Some multi-country studies have reported varying rates of substance use among in-school adolescents. For example, Peltzer and Pengpid [ 15 ] found 0.9% lifetime cannabis use and 1% lifetime amphetamine use among in-school adolescents from five Asian countries. However, individual country estimates of marijuana use among adolescents in sub-Saharan Africa range from 5 to 28% [ 16 , 17 , 18 ]. These high rates of marijuana use have been reported to have associated comorbid substance use and mental health problems.

Estimates of amphetamine use from individual countries in SSA range from 7 to 10% [ 1 , 18 ]. However, the WHO African Region in 2021 asserts that “[a]mphetamine-type stimulants (ATS) such as ‘ecstasy’ and methamphetamine now rank as Africa’s second most widely abused drug type”. An earlier multi-country study conducted among in-school adolescents between 2009 and 2013 reported a 4.1% current marijuana and a 5.1% lifetime amphetamine use in nine sub-Saharan Africa countries [ 19 ].

Several risks and protective factors have been associated with substance use among adolescents especially in Africa. For example, socio-demographic characteristics such as grade in school, sex-being male, and age-older adolescents [ 20 , 21 ], mental health-related factors such as depression, anxiety, suicidal behaviours and tobacco use [ 10 ], socio-environmental factors such as having experienced hunger, been bullied, having been in a physical fight and having been attacked [ 18 , 20 , 22 ] and parenting factors such as parental substance use, knowledge of activity, supervision and respect of privacy [ 18 , 20 , 23 , 24 ] are implicated.

Apart from the study on cannabis and amphetamine use by school-going adolescents in nine SSA countries by Peltzer and Pengpid [ 19 ] which examined the Global School-based Health Survey (2009–2013), no recent multi-country studies have been conducted to (1) examine the burden of substance use (alcohol, marijuana and amphetamine) among adolescents using the most recent data from in-school adolescents in SSA (2012–2017) as well as (2) explore the risk and protective factors of substance use to inform targeted school-based and other public health interventions. The study by Peltzer and Pengpid [ 19 ] only examined cannabis and amphetamine without alcohol which has become a major public health issue among youth worldwide and in SSA in particular. This current study fills this gap by examining the prevalence and associated factors of substance use (alcohol, marijuana and amphetamine) among in-school adolescents in eight SSA countries to inform policy, practice and education.

Data and sample

Secondary data were used for this study. Data were obtained from the Global School-based Student Health Survey of 8 countries in SSA (N = 16,318) between 2012 and 2017 (see Table  1 ). The Global School-based Health Survey is sponsored by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) to collect data on health behaviours and their associated factors in school-going adolescents across several low-income and middle-income countries. Health behaviours and related factors include alcohol use, dietary behaviours, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco use, violence and unintentional injury. Data collection involved closed-ended questionnaires administered to in-school adolescents in the various countries. Multi-stage sampling technique was used and the eligible sample sizes from the eight countries are summarized in Table  1 . For this study, 16,318 adolescents across the eight countries had the complete set of the study variables.

Study variables

Outcome variables.

There were three main outcome variables in this study (current alcohol use, current marijuana use and lifetime amphetamine use). Single items were used to measure each of the outcome variables. Current alcohol use was measured with the question “During the past 30 days, on how many days did you have at least one drink containing alcohol?” Responses ranged from 1 = 0 days to 7 = All 30 days. The responses were further recoded as 1 = 0 (No) and 2 to 7 = 1 (Yes). Current marijuana use was measured with the question “During the past 30 days, how many times have you used marijuana (also called dagga, weed, boom, cannabis, stop, grass, pipt, stop, and joint or other country-specific names)?” Responses ranged from 1 = 0 days to 7 = All 30 days. The responses were further recoded as 1 = 0 (No) and 2 to 7 = 1 (Yes). Lifetime amphetamine use was measured with the question “During your life, how many times have you used amphetamines or methamphetamines (also called tik, speed, bennies, uppers, black beauties, mollies, or splash, or other country-specific names)?” Responses ranged from 1 = 0 times to 5 = 20 or more times. The responses were further recoded as 1 = 0 (No) and 2 to 5 = 1 (Yes).

Explanatory variables

A set of explanatory variables including socio-demographic characteristics (age and sex), mental health variables (anxiety, loneliness and suicidal behaviours), socio-environmental factors (hunger, bullying, physical attack, fighting, tobacco use, cigarette smoking, truancy, and having close friends) and parental factors (supervision, connectedness, knowledge of activity and privacy) were used in the current study based on their relevance in influencing adolescents’ health-related behaviours [ 5 , 9 , 25 , 26 ].

Statistical analyses

Stata Software version 17 (Stata Corporation, College Station, TX, USA) was used for the data analysis. Data from the eight countries were extracted from the WHO website, cleaned and recoded for the analysis. To pull all the data together, the append command was used to generate one dataset comprising the eight countries. Measurements of the prevalence of substance use (alcohol, marijuana and amphetamine) in the eight were done using counts and percentages with graphical illustration (Fig.  1 ). The bivariate associations between the explanatory variables and substance use were done using Pearson’s Chi-square test, and alpha level was set at 0.05. Multivariate analysis was done using logistic regression analysis with results presented in both unadjusted (OR) and adjusted (AOR) forms for each outcome variable. The odd ratios were presented with their 95% Confidence interval with statistical significance set at 0.05. Collinearity analysis was done and the results showed VIF values between 1.01 and 1.60 with a mean of 1.20. These results showed no evidence of substantial collinearity among the study variables. In all the analyses, the survey sampling weight was applied to ensure accurateness in the estimates from the surveys.

Prevalence of substance use among adolescents in Africa

Results from Fig.  1 showed that the overall prevalence rates of substance use among school-going adolescents in SSA were 11.3%, 2% and 2.6% for current alcohol use, marijuana use and amphetamine use, respectively. Current alcohol use was highest in Seychelles (46.5%) and lowest in Tanzania (2.7%). Current marijuana use was highest in Seychelles (6.6%) and lowest in Mozambique (0.9%). The highest rate of lifetime amphetamine use was reported among adolescents in Ghana (5.5%), and the lowest rate of amphetamine use was reported among adolescents in Mozambique (0.7%).

Prevalence of current alcohol use, current marijuana use, and amphetamine use

Associations between explanatory variables and adolescents’ substance use

Findings from Table  2 showed that all the explanatory variables in exception of respect of privacy (No privacy = 11.3% vs. Privacy = 11.1%, p = 0.165) were significantly associated with current alcohol use among the school-going adolescents. All the explanatory variables except having close friends (No = 2.8% vs. 1.9%, p = 0.493) were significantly associated with current marijuana use among school-going adolescents in SSA. It was further revealed that all the explanatory variables except social connectedness (No = 2.5% vs. Yes = 2.7%, p = 0.198) were significantly associated with current amphetamine use among school-going adolescents in SSA.

Risk and protective factors of substance use among school-going adolescents

Results from Table  3 show that late adolescence (aOR = 2.63, 95%CI = 2.19–3.16), being male (aOR = 1.34, 95%CI = 1.16–1.54), anxiety (aOR = 1.86, 95%CI = 1.50–2.30), bullying (aOR = 1.49, 95%CI = 1.29–1.73), engaging in a fight (aOR = 1.32, 95%CI = 1.13–1.55), truancy (aOR = 1.49, 95%CI = 1.29–1.74), having close friends (aOR = 1.56, 95%CI = 1.22–2.00), current cigarette smoking (aOR = 5.41, 95%CI = 3.97–7.37) and tobacco use (aOR = 2.64, 95%CI = 1.93–3.59) significantly increased the odds for current alcohol use among school-going adolescents. However, parental supervision (aOR = 0.70, 95%CI = 0.60–0.82) and parental knowledge of activity (aOR = 0.63, 95%CI = 0.53–0.74) significantly decreased the odds for current alcohol use among school-going adolescents.

Anxiety (aOR = 1.90, 95%CI = 1.05–3.41), truancy (aOR = 3.20, 95%CI = 2.12–4.83), current cigarette smoking (aOR = 5.16, 95%CI = 3.03–8.79), tobacco use (aOR = 9.34, 95%CI = 5.62–15.52) and suicidal attempt (aOR = 2.21, 95%CI = 1.30–3.74] significantly increased the odds for marijuana use among school-going adolescents in SSA. However, parental knowledge of activity (aOR = 0.59, 95%CI = 0.36–0.96) and respect for privacy (aOR = 0.62, 95%CI = 0.40–0.97) significantly decreased the odds for marijuana use among school-going adolescents in SSA.

Anxiety (aOR = 2.16, 95%CI = 1.39–3.34), bullying (aOR = 2.25, 95%CI = 1.54–3.29), truancy (aOR = 1.83, 95%CI = 1.31–2.57), current cigarette smoking (aOR = 2.43, 95%CI = 1.42–4.17), tobacco use (aOR = 7.68, 95%CI = 4.91–12.02) and suicidal attempt (aOR = 1.86, 95%CI = 1.14–3.01) significantly increased the odds for amphetamine use among school-going adolescents in SSA. However, only parental respect of privacy (aOR = 0.52, 95%CI = 0.36–0.75) decreased the odds for current amphetamine use among school-going adolescents in SSA.

Substance use predisposes adolescents to several physical, psychological [ 27 ], social and academic consequences. Understanding the burden of substance use in SSA is one of the major steps in addressing the menace with focus on key identified risk and protective factors. This study addressed this gap by examining the prevalence and the associated risk and protective factors of alcohol, marijuana and amphetamine use among school-going adolescents in SSA.

Prevalence of alcohol, marijuana and amphetamine use among school-going adolescents

The overall prevalence rates of substance use among school-going adolescents in SSA were 11.3%, 2% and 2.6% for current alcohol use, current marijuana use and life time amphetamine use, respectively. The prevalence rates vary by country with school-going adolescents in Seychelles (46.5%) reporting the highest rate of current alcohol use and school-going adolescents in Tanzania (2.7%) reporting the lowest rate of current alcohol use. For current marijuana use, school-going adolescents in Seychelles (6.6%) reported the highest rate and school-going adolescents in Mozambique (0.9%) reported the lowest rate. The highest rate of lifetime amphetamine use was reported among school-going adolescents in Ghana (5.5%) and the lowest rate of amphetamine use was reported among adolescents in Mozambique (0.7%). These variations in the prevalence of substance use among school-going adolescents can be attributed to variations in the risk and protective factors of substance use within SSA countries. For example, multi-country studies in SSA have reported variations in risk factors for substance use such as bullying victimization [ 9 ], serious injuries [ 5 , 26 ], truancy [ 25 ] and suicidal behaviours [ 19 , 24 ]. Specifically, Seychelles has large tourist visits from western countries with liberal attitudes and practices regarding substance use including alcohol and marijuana which could influence school-going adolescents through observational learning. In the case of Ghana, the lack of effective drug enforcements could be one of the key contributing factors to high amphetamine use among in-school adolescents as some researchers have reported increasing use of drugs including tramadol [ 28 ]. One of the key contributing factors to these high rates and variations in substance use among adolescents in Africa could be lack of effective implementation of laws regarding substance use among underage youth in many African countries. Additionally, the easy access and availability of these substances as well as social norms [ 29 ] in the various countries might have contributed to the high rates of substance use among adolescents in Africa.

Risk and protective factors of alcohol, marijuana and amphetamine use among school-going adolescents

Findings from the study showed late adolescence (15–18 years), being male, anxiety, bullying, fighting, truancy, having close friends, current cigarette smoking and tobacco use are significant risk factors for alcohol use. Several studies conducted in individual countries have found varied risk factors for alcohol consumption among in-school adolescents in Africa. Male adolescents are reported to engage in more risky behaviours than females [ 6 , 30 ], and late adolescents have been noted for increased risky behaviours including alcohol consumption as reported in the GBD study on adolescents which found alcohol use to rank as the 3rd leading contributor to disease burden among late adolescent males [ 6 ]. The experience of mental health challenges and negative socio-environmental circumstances predisposes adolescents to the use of alcohol and other substances as a coping strategy to deal with their problems [ 10 , 14 ].

Similar risk factors were found for marijuana and amphetamine use except for the socio-demographic characteristics. For example, anxiety, truancy, current cigarette smoking, tobacco use and suicidal attempt increased the risks for both marijuana use and amphetamine use. This is consistent with most of the country-level study findings [ 18 , 31 , 32 ] and multi-country-level findings among adolescents from the Caribbean, ASEAN and some African countries [ 15 , 19 , 33 ]. The experience of bullying was a significant risk factor for amphetamine use which is a cause for concern as bullying has been reported to be pervasive among adolescents in Africa [ 9 , 34 , 35 ]. The implication of these findings is that school-based intervention programmes aimed at addressing substance use among adolescents should take into consideration mental health and socio-environmental issues that predispose adolescents to engage in substance use behaviours.

Parental knowledge of activity, supervision and respect of privacy were found be significant protective factors of substance use. The role of parental involvement in adolescents’ risky behaviours has been widely reported by previous studies [ 10 , 24 , 30 ]. This is because when adolescents are monitored and given the necessary guidance in dealing with the myriad of challenges associated with the period of adolescence, they are less likely to engage in substance use behaviours. Thus, the role of parents in any intervention programmes aimed at addressing substance use should not be overlooked.

Limitations

Although the cross-sectional study nature presents a major limitation to the findings, this study provides updated knowledge on substance use burden among in-school adolescents in SSA to inform adolescents health research, practice and policy. The different data collection years could serve as a limitation to the findings as these variations in the periods could influence the outcomes. For example, countries may have experienced different socio-economic or political environments which could have impacted on substance use among the adolescents. Due to the self-report nature of the data collection procedure, there could be social desirability biases which can influence the variations in the findings. It is also important to note that the prevalence of amphetamine cannot be compared with that of alcohol and marijuana since the periods of measurement differ, that is, lifetime prevalence for amphetamine and current prevalence (30days) for alcohol and marijuana. Despite these limitations, regular updates using most recent data from the Global School-based Student Health Survey is warranted. It is also important examine the trends in substance use across the various countries to understand the magnitude and patterns of substance use problems among adolescents in SSA. Wider policy-level factors were not examined in this study as the available data did not cover substance use policy variables.

Substance use among in-school adolescents is a major public health issue, and the between country variations observed in this current study in the prevalence of alcohol, marijuana and amphetamine use suggests the need for country-specific programmes adapted to the needs and available resources within each country. Mental health and socio-environmental factors are significant risk factors of substance use in Africa, and urgent efforts are needed using a multi-sectoral approach to address this menace. High risks of alcohol use in adolescence could escalate into heavy alcohol use and alcohol dependence. Tobacco and alcohol use are ‘gateway’ substances that facilitate experimentation of marijuana and methamphetamine, and addressing these through public health policies could have an impact on other drug use among adolescents [ 36 , 37 ]. Amphetamine, a relatively less used substance, is now becoming a common place among in-school adolescents in SSA and therefore requires concerted efforts to holistically address it.

Availability of supporting data

Data for this study can be obtained from https://extranet.who.int/ncdsmicrodata/index.php/catalog/GSHS .

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Kugbey, N. Prevalence and correlates of substance use among school-going adolescents (11-18years) in eight Sub-Saharan Africa countries. Subst Abuse Treat Prev Policy 18 , 44 (2023). https://doi.org/10.1186/s13011-023-00542-1

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Kebogile E. Mokwena Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa Nomkanka J. Setshego Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa Mokwena KE, Setshego NJ. Substance abuse among high school learners in a rural education district in the Free State province, South Africa. S Afr Fam Pract. 2021;63(1), a5302. 16 Mar. 2021; 17 June 2021; 23 Aug. 2021 © 2021. The Author(s). Licensee: AOSIS. This is an Open Access article distributed under the terms of the , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In South Africa, many studies conducted on substance abuse among in-school youth focus on urban areas. However, anecdotal evidence suggests that rural areas are experiencing an increase in substance abuse, though there is dearth of studies in these areas. This study used a quantitative design to collect data from 629 high school learners who were in Grades 10 and 11 in public schools in rural Free State Province, to determine the prevalence of, and factors associated with substance use. The sample consisted of 46% males and 54% females. Their ages ranged from 14 to 20 years, with a mean of 16.9 years. The prevalence of substance abuse was 47% ( = 295) with alcohol consumption, cigarette and dagga smoking being the most common substances used. Socio-demographically, age and gender were significantly associated with substance abuse. While behavioural variables of physical fights, serious problems with parents and friends, poor academic performance, trouble with police, having sex without condom, and having sex and regretted the next day were significantly associated with substance abuse ( = 0.05). The prevalence of substance abuse is very high for this rural school community, which highlights the need to pay attention to rural schools regarding substance abuse challenges. substance abuse; high school; rural area; Free State province; South Africa. South Africa has a high rate of substance abuse among young people, which includes both in and out of school youth. Despite reported stigma and associated reluctance to seek treatment for substance abuse, an increase in young people aged 20 years seeking treatment for substance abuse, is an indication of the gravity of the problem. Variations in the trends of substance use have been reported between urban and rural youth, with substance use among learners in urban area being more than those in rural areas. However, rural areas are increasingly experiencing problems of adolescent substance use. Substance abuse among learners is associated with a range of criminal acts, , which includes violence and bullying. , It has also been associated with a range of mental disorders ; while socially, it is associated with social disorganisation, deviant behaviour, and social interaction with deviant groups, depending on which substances are used. Risky sexual behaviours are also likely to manifest into sexually transmitted infections. In the school environment and academic context, substance abuse has been associated with challenges in school discipline, appetitive aggression and other classroom management challenges. These frustrate the achievement of intended education outcomes, and result in poor academic performance, including possible dropping out of school. The social environment is often a significant determinant of substance abuse, with adolescents being often influenced by their peers. Other determinants of drug use among young people include: curiosity, sense of growing up, amount or lack of parental discipline and monitoring, and family cohesion. Availability and easy access of illicit drugs within the community or the household, economic hardship, high unemployment, lack of adequate social support networks, pressure to meet daily family needs, family conflicts, were all associated with use of illicit drugs. In the context of schooling, substance abuse has been significantly associated with poor academic performance, which often results in dropping out of school. , , , , The perceptions that rural areas experience less substance abuse among learners often result in inadequate attention being paid to such areas. With the precise intention of expanding substance abuse studies to areas other than cities, the purpose of this study was to determine the prevalence of substance abuse, as well as explore the associations between substance abuse and a range of demographic variables among learners in a rural school district of Free State Province, South Africa. A cross-sectional quantitative survey, using a self-developed questionnaire, was conducted among learners attending local high schools in the rural school district of Free State Province, South Africa. The study was conducted at high schools at Setsoto local municipality, Thabo Mofutsanyane District of the Eastern Free State, which is largely rural. The municipality is comprised of four rural towns namely Clocolan/Hlohlolwane, Marquard/Moemaneng, Senekal/Matwabeng, and Ficksburg/Meqheleng. According to the Census 2011, the municipality has a population of 1 10 335, and of those aged 20 years and above approximately 8.7% have no formal schooling, 22.6% have completed matric, and 6.9% have some form of tertiary education. Agriculture is the main economic activity in the municipality, and the unemployment rate of those aged between 15 and 34 is high at 46%. The study population was high school learners in public schools of Setsoto municipality. There are eight public schools in the sub-district, and using the hat method, four schools from each rural town were randomly selected. An additional school was used for the pilot study. The estimated population of Grades 10 and 11 in the eight schools is 2100. The sample consisted of learners who were in Grades 10 and 11 at the time of data collection. From estimated population size of 2100 from eight schools, the Raosoft sample calculator was used to determine a minimum sample for the study. Using a 5% margin of error, a confidence level of 95% and a distribution of 50%, a minimum sample size of 323 was calculated. Because a survey was used, in which all learners willing to participate in the study were invited, 800 learners in 42 classrooms participated, but 629 were analysed, with the rest having missing information of more than 10%. Recruitment was done at the identified school, with the researcher addressing the Grades 10 and 11 learners by telling them about the study and requesting them to participate. Those who agreed to participate were given letters for their parents to provide informed consent. An English self-administered questionnaire, which was modified from a risk behaviour survey, was used to collect data. The tool was pilot tested among 20 learners at another school before data collection. The tool collected learner-related demographic data like age, gender, grade, and whether they have ever repeated a class, as well as the socio-economic data of the family, such as employment status of parents, highest education attained by the parents and who the participants live with. Substance use related data collected included the substances of current use, age at which they first experimented with substances, use of substances in their social environment and ease of access of substances. Behaviour related data included whether they were involved in physical fights, were in trouble with police, were engaged in risky sexual behaviour, (such as having sex without using a condom or having sex and regretted it the next day), and problems with parents and friends. On the day of data collection, learners whose parents had provided the informed consent were assembled in the school hall or classroom and an explanation about the study was repeated. The learners were given an opportunity to ask questions or seek clarification. Informed consent was administered to learners who were over the age of 18, while learners under the age of 18, whose parents had provided consent, were requested to provide assent by signing the appropriate forms. The data collection tool was then distributed to all the learners. Adequate time was given to complete the questionnaires, and the learners left the venue after all had completed the process. The data were captured into Microsoft Excel and transported to STATA version 13 for analysis. Descriptive statistics were used to analyse socio-demographic data prevalence of substance use, and these were reflected in the form of frequencies and percentages. Chi-square test was used to explore associations between a range of demographical variables and substance abuse among the sample. Statistical significance was set at ≤ 0.05. At sub-district district level, selection bias was minimised by random selection of schools. The use of the survey at school minimised selection bias as all learners in the selected grades who were prepared to participate were included in the study. The questionnaire was pilot tested to identify any challenges before the actual data collection commenced. Ethical approval for the study was obtained from the Sefako Makgatho Health Sciences University Research and Ethics Committee (number: SMUREC/H/95/2016). Permissions to conduct the study were obtained from the offices of the Provincial Department of Education, the Thabo Mofutsanyane District of Education, the Setsoto sub-district and the management of each participating school. Informed consent was obtained from parents for participants who were younger than 18 years of age, and these minors provided assent to participate in the study. Informed consent was obtained from participants who were 18 years and above. Eight hundred (800) learners participated in the survey, and of these, 629 were analysed, with the others being excluded because of missing data of 10% or more. Of the 629 students whose data were analysed, more than half (55%) were in the age group 16–17 years followed by those aged 18 years and above (33%). Their ages ranged from 14 to 20 years, with a mean of 16.9. The prevalence of substance use among the study participants was 47%, and of those using substances, the highest proportion consume alcohol (87%) followed by cigarette (45%) and (24%) dagga smoking ( ).  Prevalence and types of substance use among learners ( = 295). Factors associated with substance use The association between substance use and selected demographic characteristics are shown in Table 2 . Substance use significantly increased with age ( p < 0.05), while the prevalence was significantly higher among males than females (53% vs. 42%, p < 0.05). A significant higher proportion of the participants were introduced to substance use by friends ( p < 0.05). There was no statistical association between substance use and grades, employment status of the parent, and whether they stay with their parents or not.  Association between demographics and substance use. Table 3 illustrates behaviours that were significantly associated with substance use.  Associations between behaviours and substance use. The purpose of the study is to determine the prevalence of substance abuse, as well as explore the association between substance abuse and a range of demographic variables. The prevalence of substance abuse among this sample is high at 47%, which is close to the 47.9% reported in a similar sample in Ethiopia, 25 but higher than the 6% reported in another study conducted in a rural setting in South Africa. 4 The finding that many learners started using substances at a young age of 15 years confirms findings of a previous study conducted in South Africa. 16 Although cigarettes and alcohol are legal, they are still illegal for minors such as most of the sample. Of greater concern is the use of illicit drugs such as dagga, nyaope, ecstasy and cocaine, which indicates criminality as these are prohibited substances. Dagga is easily cultivated and commonly used in South Africa, and nyaope is a cocktail drug that has destroyed many lives among Black communities in South Africa because of its high addictive characteristics. 26 , 27 , 28 , 29 , 30 Adolescents who use drugs have been reported to have significantly lower levels of psychological well-being and life satisfaction, 31 , 32 which implies mental and social risks for the sample. Although peer pressure may influence young people to use drugs, they still feel guilty and stigmatised by family and community, which increases the chances of social ill-health, 33 which increases the shame associated with the behaviour of using substance. 34 The challenge of substance abuse should therefore be understood comprehensively as a problem of adolescent social ill-health. Males had a significant higher prevalence of substance use than females ( p = 0.007), which is similar to previous studies which reported that males were up to 10 times more likely to use substances than females. 35 , 36 The finding that older learners are more likely to use substances than younger ones is similar to a study conducted among learners in the Western Cape, which reported the odds ratio of 1.6 among older learners. 36 Also similar is the finding that substance use by other members of the household and friends, increases the risk of use among learners two-fold. 36 These findings highlight the need for comprehensive interventions to influence the comprehensive well-being of young people, especially among young learners. Such interventions also need a community component, 37 , 38 which is likely to improve the effectiveness of substance use prevention amongst learners, and thus improve the overall well-being of these young people. Substance use has been shown to be associated with poor academic performance, 39 , 40 , 41 a serious barrier to reaching the goals of the education system. The finding of a significant association between substance use and risky sexual behaviour 42 confirms the negative impact of substance abuse on overall youth health. The significant association of substance abuse with a range of anti-social behaviours of physical fights, serious problems with parents and friends, poor academic performance, trouble with police, having sex without condom and having sex and regretted the next day, all with p -values of 0.001, are similar to the findings reported in previous studies, which reported statistically significant associations ranging from p -values of 0.001–0.05. 36 , 43 These findings put substance abuse at the centre of various problems experienced at South African schools and communities. These associations also identify the need to target substance abuse as a barrier to overall social development because the outcomes, be they academic, physical health, social and/or mental have long-term implications for the affected learners. Alcohol, cannabis and cigarettes were found to be the most commonly used substances, which is similar to another study conducted in Durban, South Africa. 44 The ease of access for these substances increases the levels of challenges as this cannot be addressed without the involvement of other sectors, including the law enforcement and behavioural scientists. The complexity of the situation also indicates the urgency of stakeholders to work together to develop interventions that are focused on both prevention and management. Currently, there are no such interventions accessible by the general learner in any South African public-school setting. Despite the challenges of substance abuse in schools, it does not seem that the Department of Education has any specific intervention to address the problem, other than relying on the Life Orientation (LO) learning area, which aims to address a wide range of learner developmental areas. which include personal, psychological, neuro-cognitive, motor, physical, moral, spiritual, cultural and socio-economic areas. 45 However, the delivery of LO has been reported to have serious challenges because of constraints at the individual, interpersonal, school, and community levels. 46 Another shortcoming of LO as a resource for substance abuse is that it is general, and does not address personal experiences, 47 and therefore is limited in assisting learners with substance abuse challenges. Of serious concern is that the Department of Basic Education’s policy on management of substance abuse in schools is neither known nor implemented, 48 which implies that there is not much at school level that addresses the serious problem of substance abuse among learners. Limitations of the study As with other survey studies, 21% of the questionnaires could not be analysed because of missing data. However, the high response rate of 78% and a relatively large sample size of 629 counteracted the non-usable questionnaires. A limitation which applies to other survey studies is the response bias, in which the sample may under- or over-estimate the population parameter. However, this potential bias was minimised by sampling from various schools and more than one class in a school. Societal lack of approval of substance abuse by learners may have contributed to bias in their responses, but this was minimised by the privacy afforded to the participants, which meant that others would not have known about their responses. The result of the study contributes to highlight the need for interventions to address the challenge of substance abuse in schools, which will improve the academic outcomes with long-term social and career impacts. As substance abuse is more of a societal rather than just a school’s challenge, the required interventions need not be limited to schools, but extend to other young people in communities, including rural areas. Recommendations It is recommended that the substance abuse problem be outsourced to public health and/or behavioural health specialist and not be left to the Department of Education, as this is not their focus areas. This will enable consistent application, monitoring and evaluation of such interventions, and enhance the implementation of necessary modifications. Acknowledgements Competing interests. The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. Authors’ contributions J.N.S. conducted the study and initiated the draft manuscript. K.E.M. supervised the study and refined the manuscript. Both authors finalised the manuscript. Funding information The study and its publication were jointly supported by the DST/NRF/Nedbank Research Chair (Substance Abuse and Population Mental Health) grant (SARCI170807259060), and the South African Medical Research Council (SAMRC) Mid-Career Scientists Programme grant (M052). Data availability Data may be available when requested from the corresponding author, K.E.M., according to data-sharing principles of Sefako Makgatho Health Sciences University. 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Search in PubMed Search in NLM Catalog Add to Search Substance use by adolescents in Cape Town: prevalence and correlates Affiliation. 1 Department of Psychiatry and Mental Health of the University of Cape Town, the Alcohol and Drug Abuse Research Group, and the Biostatistics Unit, Medical Research Council, Cape Town, South Africa. [email protected] PMID: 12507802 DOI: 10.1016/s1054-139x(02)00445-7 Purpose: The work reported in this paper was supported by grants from the World Health Organisation Programme on Substance Abuse, the United Nations Development Programme, the South African Medical Research Council, and the Medical Faculty Research Committee of the University of Cape Town.To document the prevalence rates for use of cigarettes, alcohol, and cannabis among high school students in Cape Town, and to investigate whether use of these substances is associated with a set of hypothesized psychosocial correlates. Methods: A multistage sampling procedure produced a sample of 2930 students in grades 8 and 11 at 39 high schools in Cape Town, who completed a self-administered questionnaire. The questionnaire contained items about whether the students had used various substances and that addressed the potential correlates of interest. We calculated prevalence rates with 95% confidence intervals and constructed a set of generalized estimating equations of use in the past month of cigarettes, alcohol, or cannabis on the hypothesized correlates. Results: The prevalence rates for previous month (recent) use of cigarettes, alcohol, and cannabis were 27%, 31%, and 7%, respectively. Rates were low for black females. Recent use of each of the substances was significantly associated with the number of days absent and the number of years lived in a city. Repeating a grade was significantly associated with previous month use of cigarettes and alcohol by colored (derived from Asian, European, and African ancestry) students and alcohol use by black grade 8 students (race classifications "colored" and "black" are as defined by the repealed population Registration Act of 1950). Not being raised by both parents was significantly associated with cigarette smoking by black and colored students, alcohol use by colored students, and cannabis use by female students. It was inversely associated with cigarette use by black students. Conclusions: It is necessary to identify the factors that protect black female adolescents from substance use. It is important to address demographic factors such as race classification and gender analytically if one is to avoid obscuring differences among groups. Copyright Society for Adolescent Medicine, 2003 PubMed Disclaimer Similar articles Substance abuse and behavioral correlates of sexual assault among South African adolescents. King G, Flisher AJ, Noubary F, Reece R, Marais A, Lombard C. King G, et al. Child Abuse Negl. 2004 Jun;28(6):683-96. doi: 10.1016/j.chiabu.2003.12.003. Child Abuse Negl. 2004. PMID: 15193855 Prevalence and correlates of substance use among high school students in South Africa and the United States. Reddy P, Resnicow K, Omardien R, Kambaran N. Reddy P, et al. Am J Public Health. 2007 Oct;97(10):1859-64. doi: 10.2105/AJPH.2006.086330. Epub 2007 Aug 29. Am J Public Health. 2007. PMID: 17761580 Free PMC article. Association between psychopathology and substance use among school-going adolescents in Cape Town, South Africa. Saban A, Flisher AJ, Distiller G. Saban A, et al. J Psychoactive Drugs. 2010 Dec;42(4):467-76. doi: 10.1080/02791072.2010.10400709. J Psychoactive Drugs. 2010. PMID: 21305911 Risk-taking behaviour of Cape Peninsula high-school students. Part V. Drug use. Flisher AJ, Ziervogel CF, Chalton DO, Leger PH, Robertson BA. Flisher AJ, et al. S Afr Med J. 1993 Jul;83(7):483-5. S Afr Med J. 1993. PMID: 8211485 A systematic review and meta-analysis of substance use among medical students in India. Sahu A, Bhati N, Sarkar S. Sahu A, et al. Indian J Psychiatry. 2022 May-Jun;64(3):225-239. doi: 10.4103/indianjpsychiatry.indianjpsychiatry_672_21. Epub 2022 Jun 8. Indian J Psychiatry. 2022. PMID: 35859560 Free PMC article. Review. Tobacco use and behaviour among South African adolescents and young adults: systematic review and meta-analysis. Londani M, Oladimeji O. Londani M, et al. BMJ Open. 2024 Feb 26;14(2):e079657. doi: 10.1136/bmjopen-2023-079657. BMJ Open. 2024. PMID: 38413155 Free PMC article. Risk factors for alcohol use among adolescents: The context of township high schools in Tshwane, South Africa. Mmereki B, Mathibe M, Cele L, Modjadji P. Mmereki B, et al. Front Public Health. 2022 Oct 19;10:969053. doi: 10.3389/fpubh.2022.969053. eCollection 2022. Front Public Health. 2022. PMID: 36339189 Free PMC article. Substance use amongst high school learners in the south of Johannesburg: Is this the new norm? Mohale D, Mokwena KE. Mohale D, et al. S Afr Fam Pract (2004). 2020 Dec 10;62(1):e1-e6. doi: 10.4102/safp.v62i1.5122. S Afr Fam Pract (2004). 2020. PMID: 33314944 Free PMC article. Substance use and sociodemographic correlates among adolescents in a low-income sub Saharan setting. Abio A, Sezirahiga J, E Davis L, L Wilson M. Abio A, et al. J Inj Violence Res. 2020 Jan;12(1):21-27. doi: 10.5249/jivr.v12i1.1195. Epub 2019 Nov 24. J Inj Violence Res. 2020. PMID: 31760392 Free PMC article. Illicit Drug Use and Social Victimization among Thai Sexual and Gender Minority Adolescents. Guadamuz TE, Cheung DH, Boonmongkon P, Ojanen TT, Damri T, Samoh N, Cholratana M, Ratchadapunnathikul C, Sass J. Guadamuz TE, et al. Subst Use Misuse. 2019;54(13):2198-2206. doi: 10.1080/10826084.2019.1638936. Epub 2019 Jul 18. Subst Use Misuse. 2019. PMID: 31317813 Free PMC article. Publication types Search in MeSH Related information PubChem Compound PubChem Substance LinkOut - more resources Full text sources. Elsevier Science MedlinePlus Consumer Health Information MedlinePlus Health Information Miscellaneous NCI CPTAC Assay Portal Citation Manager NCBI Literature Resources MeSH PMC Bookshelf Disclaimer The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited. Announcements About AOSIS South African Journal of Psychiatry Editorial Team Submission Procedures Submission Guidelines Submit and Track Manuscript Publication fees Make a payment Journal Information Journal Policies Frequently Asked Questions Reviewer Guidelines Article RSS Support Enquiry (Login required) Aosis Newsletter Open Journal Systems Godswill N. Osuafor Population Studies and Demography, North-West University, Mafikeng, South Africa Osuafor GN. Alcohol and drug use as factors for high-school learners’ absenteeism in the Western Cape. S Afr J Psychiat. 2021;27(0), a1679. 14 Jan. 2021; 14 Oct. 2021; 14 Dec. 2021 © 2021. The Author(s). Licensee: AOSIS. This is an Open Access article distributed under the terms of the , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. School absenteeism has been studied in detail in relation to health risk behaviours using cross sectional studies. The aim of this longitudinal study was to examine the association amongst alcohol, drug use and high-school learners’ absenteeism. This study was set in the Western Cape. Data were collected at three separate time points from 2950, 2675 and 2230 grade 8 learners aged 13–18 years old on school absenteeism, alcohol and drug use and sociodemographic characteristics. Associations between school absenteeism, alcohol and cannabis and sociodemographic factors use were examined using descriptive and chi-square analyses. Binary logistic regression was performed using generalised linear mixed model analyses. Results revealed that 9.3% of the learners were absent for 2 weeks in the 15 weeks of the school year. Alcohol consumption ( = 34.1, < 0.001; odds ratio [OR]: 1.64 (1.38–1.94), < 0.001) and smoking cannabis ( = 49.9, < 0.001; OR: 2.01 (1.65–2.45), < 0.001) were associated with school absenteeism at bivariate and multivariate analyses. Furthermore, alcohol (OR: 1.42 (1.06–1.89), < 0.05) and cannabis (OR: 1.57 (1.11–2.22), < 0.05) use remained robust in predicting learners school absenteeism after adjusting for age, sex and socioeconomic status. These findings suggest that alcohol consumption and smoking cannabis are contemporary factors associated with school absenteeism. Therefore, interventions to ensure learners’ consistent attendance to school should integrate prevention of alcohol and cannabis use. school absenteeism; alcohol use; cannabis smoking; learners; longitudinal study. Substance use has been studied in great detail in relation to adolescents’ health risk behaviours in South Africa. However, studies on substance use and school absenteeism have not been adequately investigated. Associations between substance use and absenteeism were conspicuously missing in several studies conducted among school going adolescents in South African provinces. In Limpopo province, studies have shown that alcohol use among school going adolescents was a serious public health concern. , , In another study in the Western Cape province, alcohol use and other drug use were associated with risky sexual behaviours between grades 8–10 learners. Govender et al. in multi-system model of risk and protective factors found that alcohol consumption by adolescents was associated with sexual risk behaviour in KwaZulu-Natal (KZN) province. Of all these studies conducted among school going adolescents in South Africa, none investigated the relationship between substance use and school absenteeism. Studies elsewhere have also neglected the association between substance use and adolescent school absenteeism in a cross-sectional study that examined school absenteeism amongst 704 students aged 10–15 years in Delhi. They found that age, male sex, increasing birth order, low parental education and income predicted school absenteeism. The study further revealed that school truancy, school phobia and family reasons were predictors of school absenteeism. Despite the robustness of the study, the link between substance use and school absenteeism was not investigated. There is paucity of literature that overtly assesses the nexus of substance use and school absenteeism. In a cohort of 1259 and 1076 grade 9 learners, alcohol consumption was associated with poor academic performance and absenteeism in KZN, South Africa. Heradstveit et al. studied the association amongst alcohol, drug use and a low-grade point average (GPA) and school attendance in Norway. They utilised registry-based data on school-related functioning from 7874 adolescents and found that alcohol and drug consumption were consistently associated with low GPA and school absenteeism. The study further demonstrated that alcohol and illicit drug use remained statistically significant predictors of school-related negative outcomes after adjusting for gender, age, socioeconomic status (SES) and mental health problems. The authors concluded that alcohol and drug use are important factors for school-related problems independent of mental health problems in Norway. Soares et al., in a cross-sectional study, examined the association between the consumption of alcohol and other drugs with school absenteeism and found that high-school children who consumed alcohol, tobacco, inhalant products and marijuana were prone to be absent from school in Brazil. School absenteeism is an indicator of social exclusion and is a risk factor for selfharm and suicidal ideation in children and adolescents. Aside from negative outcomes of school absenteeism, few studies have demonstrated that consumption of alcohol and drugs have several consequences ranging from school absenteeism, , school disengagement, poor academic performance , and ultimately dropping out of school. , , A hierarchical longitudinal study of grade 9–12 leaners showed that frequent binge drinking was associated with low likelihood of high academic performance and school engagement in Ontario and Alberta, Canada. Other studies in South Korea and France have shown association between illicit drug use and other school negative consequences. School absenteeism is a crucial matter with a multitude of negative consequences. Furthermore, the relationship between chronic absenteeism and substance use is difficult to fully understand because of methodological issues. Gakh et al. in an integrative literature review demonstrated that the relationship between school absenteeism and substance use provided a limited understanding of how and why this association manifests. Using cross-sectional and local-level data often limits nuanced investigation on substance use and school absenteeism. Therefore, Gakh et al. called for absenteeism research that uses longitudinal methods and national data, which articulate methodologies and self-appraised limitations. There is a deficit of longitudinal studies on substance use and school absenteeism in South Africa. Therefore, the present study was designed to examine association between substance use and adolescents school absenteeism using longitudinal data. The Western Cape Department of Health, the Western Cape Department of Basic Education and a number of non-governmental organisations (NGOs) in conjunction with the Centre for the Support of Peer Education rolled out a longitudinal survey on the Evaluation of Peer Education in Western Cape Schools Programme (EPEP). Data were collected on change in attitudes, knowledge and behaviour on a set of pre-identified indicators in relation to peer education and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) from grade 8 and grade 9 learners between February 2012 and June 2013. The present study was a longitudinal quantitative secondary research derived from the EPEP data. Grade 8 learners were recruited from 236 schools in the Western Cape. Data were collected at three-point times from 2950, 2675 and 2230 learners of age range 13–18 years. Data were collected from the respective schools using a self-administered survey questionnaire accessible in English, Afrikaans and Xhosa through the assistance of trained fieldworkers. The dependent variable examined in the study was school absenteeism. We used Kearney’s definition of problematic absence of having more than 2 weeks (15%) absenteeism during the 15 weeks in the school year. Learners who reported absence from school for 2 weeks were coded 1; otherwise they were coded 0. The main independent variables were alcohol and cannabis use. To measure substance use, learners were asked whether they had consumed alcohol in the past 6 months prior to the survey. They were further asked if they have consumed cannabis in the past 6 months before the survey. Those who reported ‘yes’ to having consumed alcohol or smoked cannabis were assigned 1; otherwise they were assigned 0 suggesting no use of alcohol or cannabis. Other independent variables included were learners’ socio-demographic characteristics (age, sex, population group, place of residence, family structure, SES). Learners were asked to respond to four statements on basic human needs: first, ‘we don’t have enough money for food’; second, ‘we have enough money for food, but not other basic items such as clothes’; third, ‘we have enough money for food and clothes, but are short for other things’ and; fourth, ‘we have enough money for food and clothes, and also a bit extra for other things’. Responses 1 and 2 were categorised as low SES; responses 3 and 4 were categorised as middle and high SES, respectively. School factors were assessed on participation in a peer education programme and participation in school sports. Finally, individual factors were assessed on participation in religious activities and attending a youth group for HIV/AIDS. The three-time point data were restructured, and generalised linear mixed model analyses were performed using Statistical Package for the Social Sciences (SPSS) version 25. Given the relevance of sex, substance use and school absenteeism in the study, non-responses to sex, substance use and school absenteeism were excluded from the analysis. Descriptive statistics was carried out for all the variables at the univariate level. Chi-square analyses were carried out to ascertain the association between the predictor variables and school absenteeism. Predictor variables that were not significant at bivariate level were removed at multivariate analyses. At multivariate analyses, unadjusted and adjusted models of predictors of school absenteeism were presented as odd ratios (OR) and 95% confidence interval (CI). Ethics approval was obtained from the Western Cape Education Department and Research Ethics Committee of the Human Sciences Research Council (HSRC), which is nationally accredited by the South African Government. Given that most learners were under the age of 18 years, approval of the parent or guardian was sought by completing the informed consent forms. Furthermore, assent was obtained from the learners who participated in the study. showed that 1 in 10 of the learners had been absent from school for 2 weeks during the 15 weeks in the school year. Two-third of the learners were 14 years old. Over a quarter (34.4%) have consumed alcohol, whereas less than a quarter (16.0) have smoked cannabis in the past 6 months. Black and coloured learners constituted 48.3% and 47.7% of the population group, respectively. Slightly over half (55.5%) of the learners were females. Half (50%) of the learners were residing in the urban area. About two-fifth of the learners belong to high-SES status. In terms of family structures, about half were living with single parents and over a quarter with both parents. About two-third (61.5%) participated in school sports, whereas less than a quarter (16.0%) participated in peer education programmes. With regard to individual factors, the majority (78.1%) of the learners participated in religious activities, and about two-third had never participated in youth group for HIV and AIDS in the last 12 months.  Sociodemographic profile of the learners in selected schools in the Western Cape. Table 2 presents the associations amongst school absenteeism, substance use and socio-demographic factors. Using alcohol ( p < 0.001) and smoking cannabis ( p < 0.001) during the last 6 months was significantly related to the 2 weeks of school absenteeism.  School absenteeism relationship with substance use and sociodemographic factors. Sociodemographic risk factors associated with higher percentages of school absenteeism included: increasing age, low SES, being black, being male, residing in rural area and living with grandparents. School factors showed that participating in school sports was not associated with absenteeism from school. Surprisingly, participating in a peer education programme as educator showed highest percentage in school absenteeism. However, participating in religious activities and attending a youth group for HIV and AIDS was not associated with school absenteeism. Table 3 presents the results from the multivariable models. In both unadjusted and adjusted analyses, alcohol consumption and smoking cannabis significantly increased the likelihood of school absenteeism amongst learners. Similarly, increasing in age significantly predicted school absenteeism. Compared to learners from low-SES, those from middle-SES and high-SES showed 43% and 42% reduced odds of school absenteeism. Similarly, learners living with both parents had 40% reduced odd of school absenteeism compared with those residing with single parents. Again, learners were 1.5 times more likely to be absent from school if they were participants in a peer education programme compared to those who did not participate in the programme. However, in unadjusted models, sex, population group and place of residence were significantly associated with school absenteeism that disappeared in the adjusted analyses.  Predictive models of school absenteeism based on multivariate regression analyses. The aim of this study was to examine the association amongst learners’ alcohol use, smoking cannabis and school absenteeism. Incidence of school absenteeism is escalating with cascades of negative consequences and is thus considered as a public health issue in lower-middle income and high-income countries. Our findings are comparable with other studies, 6 , 20 which have documented 7.3% – 17.8% prevalence of absenteeism amongst high school learners. Other studies have reported 36.2% prevalence when absenteeism was measured in days. 9 The concern does not end with school absenteeism. However, school absenteeism gives rise to more complex school problems leading to school dropout 13 , 17 , 21 , 22 and endangered transition to promising adulthood. 13 Flisher et al. 21 suggested that preventing episodes of absenteeism has collateral benefits in terms of reducing the extent of dropout as well as poverty alleviation. The findings corroborate with previous reports that alcohol consumption and smoking cannabis are important factors in adolescents school absenteeism. 9 , 22 , 23 In our study, the association of alcohol and cannabis use with school absenteeism remained statistically significant and robust after adjusting for age, sex, population group and SES. A finding that is consistent with studies in Norway. 8 However, our findings contradict the studies in Australia and the United States of America that indicated that association between alcohol use and school attendance disappeared when adjusted for confounding factors. 23 The discrepancies between the findings of the previous studies and the present study could be attributed to the conceptualisation of the confounding variables. Our findings suggest that alcohol consumption and smoking cannabis has exclusive contribution to learners’ school absenteeism. Few studies have investigated the nexus of alcohol and cannabis use with learners’ school absenteeism along with other confounding factors such as age, sex, population group and socioeconomic factors. We explored the sociodemographic factors contributing to school absenteeism. The finding that increasing age was associated with school absenteeism is consistent with previous reports in New York. 20 Increasing age may lead to less school connectedness because of alienation with the younger learners. However, this contrasts with studies in Norway 6 and Tamil Nadu, 24 which indicated that age was not a factor in school absenteeism. Consistent with previous findings in Norway, socially economic advantaged learners were at lower risk of being absent from school. 6 Previous studies in South Korea 16 and France 17 have linked school absenteeism with poverty and socially disadvantaged background of the learners. Ingul et al. 25 further showed that parental unemployment has been associated with adolescents’ school absenteeism. Our results revealed that learners who participated in peer education programmes were more likely to be absent from school. This is a significant cause for a concern as the purpose of a school peer education programme is to empower the learners for development and self-efficacy against health risk behaviour. The absence of learners from school would mean defeating the aim of school peer education programme that may have far-reaching negative consequences for the learners. Limitations The definition of absenteeism (more than 10 days or 15%) chosen in the study accounted for all aspects of non-attendance with no causal inference. 19 The study was conducted in the Western Cape province and may fall short in accounting for school absenteeism in other setting within South Africa especially if their substance use patterns and sociodemographic characteristics varies. The present study used longitudinal data to address socioeconomic context of school absenteeism, making it a comprehensive study to assess the nexus of substance use and school absenteeism. The study has demonstrated that consumption of alcohol and smoking cannabis are important factors contributing to school absenteeism. Learners who were participants in peer education programmes showed high tendency of absenteeism from school. It seems that their absenteeism may be attributed to not having a specific role to carry out in the school peer education programme. It was unexpected that sex, population group and place of residence did not act as risk factors for absenteeism at adjusted level, given that they showed significant associations at bivariate and unadjusted analyses. However, the highlight of the study was that risk factors for school absenteeism encompassing sociodemographic, family and individual factors were examined in the study. Recommendation Given that alcohol and cannabis use remained robust in predicting school absenteeism, every strategy in reducing episodes of absenteeism should focus on preventing adolescents’ alcohol and cannabis use. Measures should be ensured to identify leaners at risk of alcohol and cannabis use as well as those in low-SES families, as they were prone to be absent from school. Furthermore, school peer education programme should be expanded to give some responsibility to learners who feature in the programme as mere participants. Acknowledgements We are grateful to Human Sciences Research Council (HSRC) for providing us the evaluation of peer education in Western Cape schools: A longitudinal study (EPEP). Competing interests The author declares that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. Author’s contributions G.N.O. is the sole author of this article. Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Data availability Data used in the study can be accessed upon reasonable request. 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School absenteeism in a rural area in Tamilnadu. Indian Pediatr. 2002;39(9):847–850. Ingul JM, Klöckner CA, Silverman WK, Nordahl HM. Adolescent school absenteeism: Modelling social and individual risk factors. Child Adolesc Ment Health. 2012;17(2):93–100. https://doi.org/10.1111/j.1475-3588.2011.00615.x Crossref Citations Subscribe to our newsletter Get specific, domain-collection newsletters detailing the latest CPD courses, scholarly research and call-for-papers in your field. South African Journal of Psychiatry    |    ISSN: 1608-9685 (PRINT)    |    ISSN: 2078-6786 (ONLINE) ISSN: 2078-6786 An official website of the United States government The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Publications Account settings Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now . Advanced Search Journal List World J Psychiatry v.12(10); 2022 Oct 19 Substance use and substance use disorders in Africa: An epidemiological approach to the review of existing literature Olakunle james onaolapo. Behavioral Neuroscience Unit, Neuropharmacology Subdivision, Department of Pharmacology, Ladoke Akintola University of Technology, Ogbomoso 210214 Oyo, Nigeria Anthony Tope Olofinnade Department of Pharmacology, Therapeutics and Toxicology, Lagos State University, Ikeja 100001, Lagos, Nigeria Foluso Olamide Ojo Department of Anatomy, Ladoke Akintola University of Technology, Ogbomoso 210214, Oyo, Nigeria Olufunto Adeleye Joshua falade. Department of Mental Health, Afe Babalola University, Ado-Ekiti 360282, Ekiti, Nigeria Adejoke Yetunde Onaolapo Behavioral Neuroscience Unit, Neurobiology Subdivision, Department of Anatomy, Ladoke Akintola University of Technology, Ogbomoso 210214, Oyo, Nigeria. moc.oohay@yibiyabgeda Corresponding author: Adejoke Yetunde Onaolapo, MBBS, MSc, PhD, Reader (Associate Professor), Behavioral Neuroscience Unit, Neurobiology Subdivision, Department of Anatomy, Ladoke Akintola University of Technology, Old Oyo/Ilorin Road Ogbomoso P.M.B 4000, Ogbomoso 210214, Oyo, Nigeria. moc.oohay@yibiyabgeda The relationship between man and substances that have abuse potentials, and whose use has been associated with the development or progression of substance use disorders has continued to evolve in terms of geography, economic implications, and time. History shows that local plants with psychoactive constituents can get exported worldwide through global travel, commerce, or even conquest. Time and globalization also change people’s relationship with substances of abuse; hence, an area that was initially alien to certain substances might evolve to becoming a trafficking hub, and then a destination. A case in point is Africa where a rapidly increasing prevalence of substance use/abuse and substance use disorder among adolescents and young adults is putting enormous strain on the economy, healthcare system, and society at large. However, there appears to be a paucity of scientific literature and data on the epidemiology, risk assessment, and contributing factors to substance use and the development of substance use disorders across Africa. In this narrative review, we examine extant literature (PubMed, Google scholar, Medline) for information on the prevalence, trends, and influencers of substance use and the development of substance use disorders. This is with a view of understanding the determinants of substance use and factors that influence the development of substance use disorders in the region, and how this information can be channeled towards developing a comprehensive intervention and treatment program. Core Tip: Substance use for medicinal and recreational purposes dates back centuries; however, in recent times, substance use is increasingly becoming a global public health crisis. In Africa, there is a consensus that substance use is emerging as a public health crise, but there appears to be a paucity of data on the epidemiology, risk assessment, and contributing factors to substance use and the development of substance use disorders across Africa. Here, we examined the extant literature for information on the prevalence, trends, and influencers of substance use and substance use disorders as it relates to Africa. INTRODUCTION Substance use and substance use disorders are increasingly becoming a global public health crisis, largely due to their increasing prevalence, worsening disability-adjusted life years, and high socioeconomic burden[ 1 ]. According to the World Drug Report, 2021[ 2 ], approximately 275 million people used drugs worldwide in the preceding year, with another 36 million persons diagnosed with substance use disorders globally[ 2 ]. In 2019 alone, substance use disorders were linked to about 18 million years of healthy life lost. Also, about 180000 deaths were directly linked to substance use disorders, while another half million deaths were attributed to illicit drug use[ 3 ]. Substance use is generally defined as a patterned use of any substance (including alcohol and/or psychoactive drugs) in quantities (or through methods) that are harmful to the user or others[ 4 ]. Substance use is often associated with varying degrees of intoxication, which is associated with alteration of judgment, attention, and perception. The use of alcohol, illicit drugs, and illegal use of prescription medications has been associated with negative impact on the individual’s health and productivity, as well as a high socioeconomic burden on the family and society[ 5 , 6 ]. Globally, there is a rapidly rising prevalence of substance use and substance use disorders, with an associated increase in the morbidity and mortality. Also, in Africa, the use of illicit substances such as cannabis (the most widely used substance in Africa, with a prevalence of between 5.2% and 13.5% in West and Central Africa), amphetamine-type stimulants, and benzodiazepines is increasing rapidly[ 7 ]. Again, in the last decade, Africa has begun to be recognized as a consumer and a destination for illicit drugs, compared to being previously regarded as mainly a transit zone for these drugs (serving as a link between Latin America and Europe)[ 8 , 9 ]. This reversal of the illicit drug trend is believed to be a contributing factor to the rapid development of substance use epidemic, particularly in the urban centers of Africa. There is a consensus that substance use (particularly among adolescents and young adults) in Africa is emerging as a public health crises; however, there appears to be a paucity of scientific literature and data on the epidemiology, risk assessment, and contributing factors to substance use and the development of substance use disorders across Africa. Here, we reviewed the extant literature for information on the prevalence, trends, and influencers of substance use and the development of substance use disorders. This is with a view of understanding the determinants of substance use and the factors that influence the development of substance use disorders in the region, and how this information can be channeled towards developing a comprehensive interventions and treatment program. History of substance use and substance use disorders Substance use for medicinal, religious, and recreational purposes dates back centuries. The earliest mentions of the use of alcoholic or fermented beverages in Chinese writing dates far back as the 7 th millennia B.C.E[ 10 ], although there is also evidence from Sumerian writing (2100 B.C.E) of the use of opium from the poppy plant[ 11 ]. While the earliest use had been linked mainly to medicinal and religious purposes[ 10 - 12 ], there are also documentations of their use for recreational purposes[ 12 ]. However, since ancient times, humans have recognized the health problems that may be associated with excess alcohol consumption[ 12 - 14 ]. In 2019, the United Nations Office on Drugs and Crime reported an estimated 35 million people having a substance use disorder necessitating treatment[ 15 ]. Surveys and results of prospective studies examining patterns of drug use among the general population has revealed substance use peaks between 18 years and 25 years of age[ 15 , 16 ] with drug use among young people exceeding that of older people[ 15 , 17 ]. History of substance use in Africa: From transit nations to major illicit drug destinations The African continent has a long history of drug cultivation, production, trade and consumption; and there are also indigenous plants and herbs with psychoactive effects such as cannabis resin (known as hashish in North Africa), Catha edulis (known as Kath in East Africa), and cannabis (known as dagga in Southern Africa) that have also been used traditionally for centuries[ 18 - 21 ]. In the last few years, rapidly growing large-scale trade and recreational use of opiates, synthetic psychoactive stimulants, and prescription drugs are emerging threats in the African continent[ 21 ]. The relationship between North Africa and cannabis has existed for centuries, predating the arrival of the Spanish and French in the 19 th century. Also, during the colonial era, cannabis was cultivated in small quantities across the northern Rif mountains in Morocco, and throughout the northern parts of Tunisia and Algeria[ 22 ]. While production was mainly to meet local demands (with some smuggling and exportation to Europe), the era following independence of the different countries in the region saw regulations and laws being enacted and enforced to control the production, sale, and use of cannabis. However, across the four countries (Morocco, Algeria, Tunisia and Libya) that make up the Maghreb (an area also known as northwest Africa), the drug trade has not only continued to grow, it is also evolving. In the last few decades, a region known mainly for the production of cannabis destined for other markets (particularly the European market) has increasingly become an important route for the trafficking of cocaine and different psychotropic pills. Since the beginning of the 21 st century, trafficking routes for cocaine, cannabis resin, and psychotropic pills that existed between South America, Africa, and Europe shifted to transect the Maghreb region[ 22 ]. This change has been partly attributed to an increase in the demand for drugs in the region, and the perturbations of other transit zones such as the Sahel region, which has become unstable. Most important is the geographic location of the region, being a link between Africa, Middle East and Europe. While drug transit routes through North Africa is increasing, of more importance is the increasing rate of consumption of these drugs in the region. The use of psychotropic drugs, which are very addictive, is nearing epidemic proportions in the region; also, other substances being consumed include cannabis, cocaine and opioids[ 22 ]. Before West Africa began to be considered a transit zone for drugs, it was also a producer of cannabis products (although not on the scale of the North African countries), which were shipped to Europe and the United States. Although, at the same time, marijuana was being imported into Nigeria from South Africa and a region now known as the Democratic Republic of Congo[ 23 ]. The smuggling of heroin through West Africa was first documented in 1952[ 23 ]; however, West Africa’s rise as a major drug smuggling hub began sometime in the 1960s, coinciding with a period of increased demand for illegal drugs, including marijuana which was grown and exported from Nigeria in large quantities to Europe. Despite attempts by governments in these countries to stem the tide of the marijuana export, marijuana trade continued illegally for several years until the demand for newer psychoactive substances such as cocaine and heroin overtook the demand for marijuana[ 24 ]. By the 990 th year of the 2 nd millennium and the 90 th year of the 20 th century, West Africa had become a major transit and repackaging center for substances such as cocaine and heroin through a transnational trade route that originated from South America and Asia, to Europe. While drug trafficking through Africa was not new, an intense clamp-down on the South-North American trade routes by the United States anti-narcotics strategies and the increase in demand for drugs across Europe saw to the rapid expansion of the West African trade routes in the early 21 st century[ 25 , 26 ]. The geography of the West African states (made up of large areas of uninhabited islands and archipelagoes found in countries like Guinea Bissau) eased transit and made detection difficult[ 27 ]. Also, the vulnerable political environment with the presence of civil wars/insur-gencies created fertile grounds for the development of criminal networks in the West African sub region[ 27 ]. Previously, when compared to West Africa, the drug trafficking routes through the Eastern belt of Africa were less robust; however, in the last few decades of this century, the trend is an increase in the trafficking of and the variety of trafficked drugs through the East African states of Kenya, Uganda, and Tanzania. Specifically, the trafficking of heroin and cocaine through these countries has grown considerably. Trafficking routes begin in Afghanistan where heroin is produced, through Pakistan and then East Africa enroute over Europe. The cocaine transnational trafficking routes began to go through East Africa in a bid to bypass the West African routes that were increasingly being watched by anti-drug trafficking authorities[ 28 ]. Also observed was that the increased consumption of these substances coincided with an increase in trafficking and affordability of the drugs. In South Africa, a country in the southern region of Africa, the trafficking of drugs has increased. There are reports that since the period prior to and following the transition to democracy, there has been an escalation of drug trafficking. Trafficking in these parts has increased as a result of the easing of the strict control of land, air and sea borders, and an increase in international trade that occurred following the reintegration of South Africa into the committee of nations following the end of apartheid. Also, the effective policing of traditional smuggling routes prompting the search for other shipping routes also accounts for the increased trafficking of drugs through South Africa[ 29 ]. The increased trafficking is also worsening the substance use problems as a proportion of the drugs trafficked end up on the local market. There have also been reports that drugs such as methaqualone are also produced in clandestine laboratories in the region[ 30 ]. Overall, the level of affluence in the region makes it an attractive ‘emerging market’ for illicit drugs[ 30 - 32 ]. South Africa also has a history of drug use that dates as far back as the 15 th century. Cannabis, which is known as dagga in South Africa, has been consumed traditionally for centuries. The cannabis plant was brought to southern Africa by Saheli merchants from eastern Africa and some members of the bantu tribe of central and southern Africa where it has been cultivated since the 15 th century. Around the 16 th and 18 th century, the consumption of cannabis increased significantly[ 33 ]. Although initially popular only among the African population, over time, its use extended to the white population of South Africa[ 30 ]. Overall, while the current substance use epidemic in the African continent could be linked to the global trend in substance use, the transformation of African nations from mainly transit points in the international drug network to consumer countries would seem inevitable[ 34 ]. Also, the rapid socioeconomic changes that have occurred across the different countries that make up the African continent could have facilitated this shift in what can be assumed to be the “normal trend”. EPIDEMIOLOGY OF SUBSTANCE USE ACROSS THE AFRICAN CONTINENT Across Africa, reports spanning the last two decades show that substance use especially among adolescents and young adults is increasing at alarming rates[ 19 , 35 - 41 ]. The World Health Organization and the United Nations Office on Drugs and Crime reported, an exponential increase in the per capita consumption of alcohol as well as the cultivation, trade, and consumption of cannabis in most of the countries in Africa, with suggestions that this could inevitably have adverse socioeconomic and public health implications[ 42 - 44 ]. At the time, about 10 countries in Africa were listed among the 22 countries with the highest increases in the use of alcohol and other psychoactive substances including cannabis, tobacco, cocaine, and heroin[ 45 ]. In 2013, the United Nations Office on Drugs and Crime World Drug Report estimated that across the African continent, more than 28 million people had a current history of substance use. Cannabis was also reported to be the most commonly used drug on the continent, with the prevalence estimated to be 7.5%, which was almost twice the global average. The use of opioids was also reportedly on the rise[ 46 ]. While it has been recognized that Africa is beginning to battle a drug use epidemic, with an estimated 37000 people in Africa dying annually from substance use-associated complications[ 47 - 49 ]; available data for Africa are still either weak or nonexistent. To date, in many African countries, there is still a paucity of national data regarding the epidemiology and patterns of substance use across populations, with available data largely limited to small prospective population studies and retrospective hospital-based studies. In West Africa, the paucity of data regarding the prevalence of drug use undermines our ability to adequately understand the full extent of the substance use problem, and how it is creating a public health problem that further threatens the already fragile health system that currently exists. It also creates a false sense of safety, because it fosters the erroneous belief that substance use is under control. However, in the last few years, this trend is becoming more difficult to ignore, because there is now increasing evidence from the increase in crime/criminal behaviors and an increasing need for medical attention that arises from the development of substance use disorders or complications of risky behaviors that are consequences of drug use. In the last decade, in West African countries like Ghana, incident reports from health professionals, lawyers, and law enforcement officers are beginning to show dramatic increases in the domestic consumption of illicit drugs. However, these reports do not adequately portray the scale of substance use problem; because there is a dearth of national figures that can accurately quantify the prevalence of drug use in Ghana or most other West African countries. All of these result in a huge dependence on small-scale cross-sectional studies (Table ​ (Table1). 1 ). A 2008 population-based study conducted among school-going adolescents, reported that the prevalence of any substance use in the preceding 1 mo was 3.6%[ 50 ]. The results of an earlier study that interviewed a sample of 894 high school students with a mean age of 17.4 years, reported that the lifetime alcohol use in these cohort was 25.1%; with cigarette use and lifetime marijuana use being 7.5% and 2.6%, respectively. Also, current alcohol use was reported to be 46.2%; current cigarette and marijuana use was 44.6% and 58.3%, respectively[ 51 ]. The result of a 2014 cross-sectional survey of a sample of 227 street children and youths revealed that the current prevalence of alcohol and marijuana use was 12% and 16.2%, respectively. Sex differences in substance use was also reported with more females using alcohol, marijuana, and smoking cigarettes compared to males[ 52 ]. In Nigeria, reports from small-scale studies have demonstrated a high prevalence of substance use among adolescents and young adults. A 2009 study that examined the prevalence of substance use among 280 students at a senior secondary school in a town in Northwest Nigeria, revealed that about 56% of them had a history of substance use, with the most common being kolanut, cigarettes, and marijuana[ 53 ]. Idowu et al [ 54 ] also examined the prevalence of substance use among 249 students (mean age = 16.3 ± 2 standard deviations) of secondary schools in a metropolis in south western Nigeria and reported that the prevalence of alcohol and substance use was 21.7% and 26.3%, respectively, with tramadol being the substance of choice[ 54 ]. The magnitude of the effect was best conveyed by the results of the 2018 National Drug Use Survey which revealed that approximately 14.3 million people (accounting for 14.4% of the population aged between 15 years and 64 years) had a history of current and continuing substance drug use, with close to 3 million having at least a form of drug use disorder[ 48 , 55 ]. A difference was also observed in the prevalence of drug use between the Northern and Southern geopolitical zones, with a higher prevalence in the regions in the south (13.8%-22.4% of the population) compared to those in the northern geopolitical zone (10%-14.9% of the population). In Nigeria, cannabis was the most commonly used drug, which was followed by opioids (non-prescription or in cough syrup)[ 48 , 56 ]. The survey also highlighted a rise in the current use of psychoactive substances (including cannabis), the non-medical use of prescription drugs such tramadol, codeine, morphine or cough syrups that contain codeine or dextromethorphan[ 55 ]. Also observed was an overall high incidence of drug use (excluding alcohol) among males compared to females (10.8 million males vs 3.4 million females), although the sex difference in the non-medical use of prescription opioids, cough syrups, and sedatives was not as significant (6% among men compared to 3.3 among women). The survey also reported a higher incidence of drug use among young adults (24-39) compared to those aged 24 and below[ 55 ]. Epidemiology of substance use across the African continent Ghana Population-based study School-going adolescents 3.6% prevalence of substance use in the preceding 1 mo [ ] Ghana Cross-sectional study 894 high school students with a mean age of 17.4 yr Lifetime alcohol use was 25.1%; with cigarette use and lifetime marijuana use being 7.5% and 2.6% respectively. Current alcohol use was 46.2%; current cigarette and marijuana use was 44.6%; and 58.3%, respectively [ ] Ghana Cross-sectional survey 227 street children and youths Current prevalence of alcohol and marijuana use was 12% and 16.2%, respectively [ ] Nigeria Cross-sectional study Northwestern Nigeria 280 secondary school students 56% of them had a history of substance use (kolanut, cigarettes, and marijuana) [ ] Nigeria Cross-sectional study Southwestern Nigeria 249 secondary school students Prevalence of alcohol and substance use was 21.7% and 26.3%, respectively, tramadol being the substance of choice [ ] Nigeria National drug survey Population-based Approximately 14.3 million people (accounting for 14.4% of the population aged between 15-64 yr) had a history of current and continuing substance drug use, with close to 3 million having at least a form of drug use disorder [ ] Ethiopia Demographic and health survey Population-based 4% of youths and 6.3% of individuals in age groups of 25-29 yr smoked cigarettes, while 53% of men and 45% of women consumed alcohol [ ] Ethiopia Analysis of data extracted from the 2016 Ethiopia Demographic and Health Survey 12688 male cohorts 62.5% (7931 males) had a current history of substance use (alcohol, Kath, or tobacco). Inhabitants of the Amhara, Tigray and Oromia regions had a current substance use prevalence of 18.5%, 14.2% and 12.8%, respectively [ ] Ethiopia Cross-sectional study Northeastern Ethiopia 730 university students in Lifetime prevalence of alcohol consumption, Kath chewing, and cigarette smoking was 33.1%, 13% and 7.9%, respectively, and current prevalence was 27.9%, 10.4% and 6.4% [ ] Ethiopia Cross-sectional study 794 university students 73.7% had a history of substance use with the lifetime prevalence of illicit drugs being 23.3% [ ] Egypt Hospital-based study (single-center experience) First episode drug-induced psychosis patients Substance abuse rates are as high as 10%-20% the global average with cannabis and tramadol being the most abused substance [ ] Tunisia Cross-sectional study 298 persons with a history of drug use Cannabis was the most widely consumed illicit drug, followed by benzodiazepines, buprenorphine, cocaine, and ecstasy [ ] Tunisia Mediterranean school survey project Secondary school students Tobacco, alcohol, and cannabis were the substances most frequently used [ , ] Tunisia Epidemiologic/toxicological investigation Northern Tunisia 11170 suspected drug users A preponderance of males (97.4%), with a median age of 29 ± 7.91 yr. 91.3 % were single [ ] South Africa School-based survey Secondary school students 13% of the students (aged 19 yr and below) had an history of cannabis use, although current use was 9%. 12% had a current use of heroin, 11% used inhalants and 6% consumed mandrax [ ] South Africa National household survey Population-based Past 3 mo prevalence for cannabis among 15-19-years-old was 3% [ ] In East Africa, there is also a dearth of national statistical data on the prevalence of substance use in a number of the countries, with researchers and policy makers needing to rely on information from studies involving subsets of the populations. In Ethiopia, alcohol, Kath and tobacco are the most popular substances that are consumed[ 57 , 58 ]. A 2012 Ethiopian demographic and health survey reported that 4% of youths and 6.3% of individuals in age groups of 25-29 years smoked cigarettes, whereas 53% of men and 45% of women consumed alcohol[ 59 ]. Also, the results of a study by Girma et al [ 60 ] that analyzed data extracted from the 2016 Ethiopia Demographic and Health Survey revealed that of the 12688 male cohorts of the Ethiopian Demographic and Health Survey, at least 62.5% (7931 males) had a current history of substance use (alcohol, Kath, or tobacco) as at the time of the survey. Inhabitants of the Amhara, Tigray, and Oromia regions have a current substance use prevalence of 18.5%, 14.2%, and 12.8%, respectively. Alcohol (53.1%) is reportedly the most commonly consumed substance, followed closely by Kath, which has a prevalence of 25.9%[ 60 ]. Reports of small cross-sectional studies have also corroborated the high prevalence of alcohol, Kath, and cigarette smoking among Ethiopian youths[ 61 ]. Adere et al [ 61 ] examined a cohort of 730 university students in Northeastern Ethiopia and reported that the lifetime prevalence of alcohol consumption, Kath chewing, and cigarette smoking was 33.1%, 13%, and 7.9%, respectively, whereas the current prevalence of these substances is 27.9%, 10.4%, and 6.4%, respectively[ 61 ]. The prevalence observed in this study was similar to that observed in an earlier study carried out among the students at a University in a town in North Ethiopia[ 62 ]. While earlier studies among university students did not report evidence to suggest the use of illicit drugs, the results of a 2021 cross-sectional study among 794 students of Addis Ababa University, showed that 73.7% of the study participants had a history of substance use with the use of illicit drugs having a lifetime prevalence of 23.3%[ 63 ]. However, similar to other studies, alcohol, Kath, and cigarettes were still the most commonly abused substances[ 63 ]. In North Africa, data and information on substance use, production, trafficking, and consumption are also limited. This has been attributed to a lack of capacity for data collection and analysis[ 64 ]. In Egypt, there are reports that substance abuse rates are as high as 10%-20% the global average, with cannabis and tramadol being the most abused substances[ 65 ]. In Tunisia, an increase in the trafficking and consumption of psychoactive substances have been observed since the political uprising that occurred in 2011[ 66 ]. There have also been reports of increased availability of drugs of abuse, particularly to school students[ 66 ]. These increases have been confirmed by a few epidemiological studies[ 66 - 68 ]. Moslah et al [ 68 ] carried out a study to examine the pattern of substance use among 298 persons with a history of drug use between 2010 and 2015. The results showed that among these cohort of young adults, cannabis was the most widely consumed illicit drug, followed by benzodiazepines, buprenorphine, cocaine, and ecstasy[ 68 ]. Reports from the Mediterranean School Survey Project on Alcohol and Other Drugs (II) carried out in Tunisia in 2017 revealed that tobacco, alcohol, and cannabis were the substances most frequently used by secondary school students[ 67 ], whereas psychotropic drugs such as ecstasy, cocaine, and buprenorphine were less frequently consumed. More importantly, it was observed that the frequency of use of these substances has increased significantly since the first survey published in 2014[ 66 ]. Chaouali et al [ 69 ] carried out an epidemiologic/toxicological investigation to evaluate patterns of drug abuse in 11170 suspected drug users. Urine samples collected between January 2016 and December 2018 were also analyzed. Results revealed a preponderance of males (97.4%) compared to females, with a median age of 29 ± 7.91 years. Also observed was that a large percentage of these drug users were single (91.3%). Examination of the urine samples revealed that about 48.4% tested positive for illicit drugs, with cannabis being the most widely consumed drug (95%), others were benzodiazepines, buprenorphine, cocaine, and opiates (0.13%). There was also a history of poly drug use[ 69 ]. In Southern Africa (although there are limited national data in most countries in the region), a rise in substance use has been reported[ 70 ]. In some of these countries including Zimbabwe, there is anecdotal evidence suggesting an increase in substance use among adolescents and young adults, with prevalence of substance use reportedly ranging from 6.1% to 13.8%[ 70 ]. Alcohol, cannabis, heroin, glue, and cough mixtures are among the most commonly consumed products in Zimbabwe. Cannabis, which is commonly known as mbanje, is grown locally (also smuggled into Zimbabwe from Malawi and Mozambique), and remains the most popular illicit drug among young Zimbabweans. Drugs are also trafficked through Zimbabwe to other countries in the region, including South Africa. In South Africa, an increase in substance use has been reported, which has been linked to the increased availability of illicit drugs including cannabis, cocaine, heroin, amphetamines, and ecstasy; either from diversion during trafficking or increased cultivation and local production[ 29 , 30 , 71 , 72 ]. Other factors that have contributed to the increase in substance use include an increase in migration and easing of border controls following the commencement of democracy, which have facilitated the development of youths’ movements that indirectly or directly promote substance use[ 30 ]. Results from surveys have revealed a gradual increase in cannabis consumption among adolescents and young adults in South Africa. A 2002 school-based survey reported that 13% of the students (aged 19 years and below) had an history of cannabis use, although current use was 9%. About 12% had a current use of heroin, 11% used inhalants, and 6% consumed Mandrax[ 73 ]. The results of another study (a 2005 National household survey) showed that the prevalence in the past 3 mo for cannabis among 15-19-years-old was 3%[ 74 ]. In another study examining the prevalence and patterns of use of illicit substances among persons presenting at drug treatment centers in South Africa, it was revealed that cannabis (16.9%), methamphetamine (12.8%), cocaine (9.6%), and prescription drugs (2.6%) were the substances commonly used among patients. Also, there was evidence of poly drug use, with cannabis and mandrax having a prevalence of 3.4%, whereas heroin and opiates had a prevalence of 9.2%[ 75 ]. Prior to 1994 and the first democratic elections, alcohol, cannabis, and methaqualone were the primary substances of misuse in South Africa. With South Africa’s transition to democracy and subsequent reopening of borders, there has been an influx of and a growing burden of harm associated with illicit drug use. Alcohol, however, remains the most commonly misused substance, with 14% of the population having a lifetime diagnosis of alcohol abuse and/or dependence (Herman et al [ 76 ], 2009). Although the overall levels of alcohol consumption do not exceed those in the developed world, the pattern of consumption differs markedly, with hazardous and binge drinking being common. New and emerging psychoactive substances in Africa Use of novel psychoactive substances is an emerging trend in substance use that is fast becoming a public health challenge globally[ 77 , 78 ]. Novel or new psychoactive substances have been defined by the United Nations Office on Drugs and Crime[ 79 ] as substances of abuse (existing either in its pure form or as a preparation) that are not controlled by either the 1961 or 1971 conventions on narcotic drugs and psychotropic substances, respectively, but pose significant threats to public health globally due to spikes in intoxications and fatalities associated with their use[ 79 , 80 ]. The term ‘novel’ or ‘new’ that is used in relation to these substances depicts their recent emergence in the global market. Substances that currently fall within the novel psychoactive substance category include (but are not limited to) synthetic cathinone and cannabinoids, synthetic opioids, image and performance-enhancing substances, tryptamine derivatives, piperazines, phencyclidine-like dissociatives, gamma amino-butyric acid (A)/beta receptor agonists, novel hallucinogens, benzodiazepines and psychotropic plants/herbs[ 77 , 81 , 82 ]. In the last few years or more, there has been a growing demand and supply chain for these new psychoactive substances[ 77 , 78 , 81 ]. In the last 10-12 years, the number of novel psychoactive substances has increased considerably. In 2009, only about 166 of them had been detected; however, by 2019, the number had risen to about 950, with more than 70% of these substances available in Europe[ 80 , 83 ]. While in the developed economies, a lot is being done to ensure continued documentation of novel psychoactive substances as they emerge, it would seem that Africa is only beginning to awaken to the emerging public health threat that these substances pose to her teeming population of adolescents and young adults[ 82 ]. While the lifetime prevalence of novel psychoactive substance use in countries such as the United States have been examined[ 80 ], there is a paucity of data on the prevalence of novel psychoactive substance use in Africa. Although across the continent, there is increasing awareness of the dangers of novel psychoactive substance use. In 2017, attention was called to an increase in the use of designer drugs in Nigeria. Some of these substances which have street names such as “black mamba”, Colorado”, “Lamba”, “happy boy”, and” Scooby snax” are believed to contain synthetic cannabinoids. Their use is associated with a rise in the incidence of hallucinations, convulsions, psychiatric disorders, kidney failure and fatalities[ 84 ]. News outlets, including the British Broadcasting Corporation News and Premium Times, also reported that the use of and addiction to non-conventional psychoactive substances such as tramadol and codeine cough syrups among Nigerian youths was reaching epidemic proportions[ 85 , 86 ]. In Nigeria, available novel psychoactive substances also include mixtures with street names such as “gutter water”, a cocktail of cannabis, tramadol, codeine and ethanol), and “monkey tail ” , a cocktail of locally made gin and cannabis (seeds, leaves, stems, and roots). Some people have also been in a state of euphoria from drinking the mixture of specific carbonated drinks and menthol flavored candies[ 82 ]. The sniffing of dry human fecal matter, dry cassava leaves and seeds, Datura metal seeds, Moringa leaf, burnt tires, sewer gas, and nail polish have also been reported[ 82 , 87 ]. Different parts of some lizards, including the whitish part of their dung, are also smoked in a bid to achieve a “high”[ 82 , 87 ]. The inhalation of urine, sewage, petrol, and glue are also common practice among drug users in Africa. It is believed that the hallucinogens present in hydrocarbons from petrol, and gases produced from fermentation of sewage have the ability to cause a “euphoric high” similar to (but longer lasting) when compared to that derived from the ingestion of cocaine[ 88 ]. In southern Africa, particularly South Africa, there have been reports of the use of “Nyaope” also known as “Whoonga”, which is a cocktail of low-grade heroin (black tar heroin), marijuana, antiretroviral drugs (Efavirenz), and other undisclosed substances[ 88 ]. In East African countries such as Uganda and Kenya, the habit of using novel psychoactive substances such as the sniffing of aviation gas/jet fuel, toluene and glue is reaching epidemic proportions among persons aged between 16-25 years[ 89 - 91 ]. Other substances that are abused in this region include “kuber” and“ shisha”, also known as hookahs ,which are variants of smokeless tobacco. There have been reports that compared to cigarettes, the smoking of the shisha or hookah pipe exposes the user to higher volumes of smoke containing high levels of benzene, tar, and other carcinogens and increased risk of lung cancer[ 92 - 95 ]. In Northern Africa, the smoking of hashish and the chewing of Kath has become very rampant. Although there is little data from the region regarding the prevalence and patterns of use of novel psychoactive substances; reports from studies carried out in Egypt have suggested that the estimated prevalence of novel psychoactive substance use among adolescents in the country are largely underestimated[ 96 ]. However, tabloid reports have called attention to an increasing demand and use of novel psychoactive substances including “voodoo” and “strox” among adolescents and young adult in Egypt[ 97 , 98 ]. “Voodoo” is gaining popularity rapidly, and it is usually packaged and sold as an herbal incense. “Voodoo” is a heterogeneous mixture of several psychoactive substances, including synthetic cannabinoids, tramadol, amphetamine, methadone, benzodiazepines, penitrem A (a neurotoxin) and morphine derivatives. The concentrations of the chemical constituents and adulterants of voodoo also vary substantially among the different clandestine laboratories that produce it[ 96 , 99 ]. Another novel psychoactive substance that is gaining popularity in Egypt is “Strox”[ 100 ]. “Strox” or “Egyptian Spice” has been reported to account for approximately 4.3% of the over 10400 patients requiring medical support for drug-related complications[ 101 ]. Also, addiction to “strox” was responsible for 22% of calls to the addiction center hotline[ 101 ]. “Strox” is a potent synthetic narcotic that is mixed with tobacco and smoked; it is compounded in clandestine laboratories by adding veterinary grade chemicals to aromatic herbs such as marjoram. There have also been reports of the addition of pesticides to increase the potency, although this increases the toxicity[ 97 ]. The search for novel psychoactive substances is fueled by the need to create drugs that are able to evade the chemical processes used for detection and the legal processes that criminalizes the use and possession of conventional drugs of abuse. Also, the need for compounds that deliver fast and sustained psychoactive effects when compared to the conventional drugs also drive the search for novel psychoactive compounds[ 102 ]. However, the variability of the chemical constituents and/or adulterants of the different compounds present a conundrum for the health professional who has to decipher and manage the divergent symptoms and signs that complicate the use of these substances. Hence. there is an increasing need for continuous surveillance so that new or emerging psychoactive substances can be discovered before they wreak havoc on our communities. African plants and herbs with psychostimulant potential: Are they being abused? Several plants and parts of plants have been shown to have central nervous system effects[ 103 - 109 ]. Also, current literature reveals that novel psychoactive substances can be derived from either synthetic compounds or from bioactive principles of natural compounds. These bioactive principles which are mainly alkaloids are present in a wide variety of plants including Ayahuasca, Catha edulis and nicotiana tabacum; and have been reported to possess hallucinogenic and/or stimulant effects[ 110 ]. Plants with psychoactive properties are found all over the globe and have been used for centuries by humans, for religious, therapeutic and recreational purpose[ 111 , 112 ]. Studies have shown that the bioactive principles of these plants enable the profound alteration of the human perception allowing for divination, ancestral contact, and spiritual enlightenment[ 111 - 113 ]. Africa has a high floral diversity and a rich tradition of indigenous medicinal plant and herb use[ 111 ]. Africa is also rich in flora of medicinal plants that possess central nervous system effects[ 107 ]. Although there is a paucity of ethnobotanical surveys on African plants with psychoactive effects, evidence from African traditional healers and diviners who use plants such as the ‘Ubulawu’, a preparation containing Sileneundulata and Synaptolepis are pointers that there are plants indigenous to Africa that contain compound which have mood altering effects[ 113 ]. A few plant species that are indigenous to Africa, such as the Cola species (Cola nitida, and Cola acuminata), Catha edulis (Kath), Datura species (Datura stramonium), Pausinystalia yohimbe (Burantashi Pausinytalia yohimbe) and Tabernanthe iboga have reported psychoactive properties[ 111 , 114 ], and have been used recreationally (Table ​ (Table2) 2 ) for centuries in the countries in which they are cultivated. However, in recent times, the use of and dependence on some of these plants by adolescents and young adults (either alone or combined with established illicit drugs) is reaching epidemic proportions. In this section, we reviewed the abuse potential of some psychoactive plants that are indigenous to the African continent. African plants and herbs with psychostimulant potential East Africa Khat chewing, drink made from dried leaves or smoking dried leaves Catha Edulis Phenylalkylamines and the cathedulins (Cathinone) Improves performance, stay alert and to increase work capacity, excitement, appetite loss and euphoria Memory impairment, sleeping disorders, liver toxicity, cardiovascular disease, psychosis and poor academic performance [ , , - ] West Africa Different parts of the plant are smoked or used to make concoctions Datura specie including stramonium and Datura metal Atropine, scopolamine, and hyoscamine Anticholinergic and hallucinogenic activity Hyperthermia, tachycardia, delirium, pronounced amnesia, severe mydriasis, bizarre behaviors and painful photophobia [ , , , - ] West Africa Root bark concoctions Tabernanthe iboga Ibogaine Stimulatory, hallucinogenic, and sedative effects Development of ataxia, tremor, cardiac toxicity, and death [ - ] South Africa Ubulawu drink Silene undulata and Synaptolepis Triterpenoid saponins Mood altering effects including stimulating vivid or lucid dreams Confusion [ ] South Africa Chewed, smoked, snorted or swallowed Sceletium tortuosum Mesembrenone, mesembrenol, mesembrine and tortuosamine Increased libido, decreased stress, euphoria and appetite suppression Anxiety, headache, hypertension, irritability, insomnia and nausea [ , ] Kath (Catha edulis Forsk) is a flowering plant native to countries in East Africa and the Horn of Africa. Fresh young leaves and twigs from Kath are chewed daily by large populations of people for its psycho-stimulatory properties. The chewing of Kath dates back centuries, being a practice that is rooted in tradition, social custom and the culture of the indigenous populations[ 115 ]. It has been reported that more than 20 million people worldwide chew Khat[ 116 , 117 ]. Although traditionally a custom associated with older middle Eastern and Eastern African men, Khat’s use is now expanding to include women and younger persons. In the Eastern region of Ethiopia, approximately 30% of adolescent girls and 70% of adolescent boys chew Khat. The active principle contained in Khat is cathinone (an alkaloid), which is a stimulant that causes excitement, appetite loss and euphoria[ 117 ]. In countries such as Somalia, Ethiopia, Djibouti, and Kenya, the dependence on Kath is warranting its consideration as a substance of abuse. In Somalia a law prohibiting the use, cultivation, importation and trade of Kath was enacted and enforced by comprehensive national program[ 118 ]. At about the same period (approximately two decades ago), Kath was also considered by the World Health Organization and classified as a drug of abuse, although its abuse potential was not thought to constitute a serious problem compared with that of alcohol or tobacco[ 119 ]. Across a region extending across Africa and the Middle East, predominantly among the Ethiopians, Somalians and Yemenis, approximately 5 to 20 million people use Kath[ 116 , 120 ], with the consumers engaged in the practice for the best part of a day resulting in a loss of manpower and national income[ 121 , 122 ]. In 2005, a survey by the World Health Organization revealed a prevalence of 20% Kath abuse in Kenya, exceeding the prevalence observed in most of the other countries in the region[ 123 ]. However, more recent studies are demonstrating that in spite of attempts by the respective countries to criminalize the use of Kath, Kath chewing is fast becoming a common practice among young adults in countries like Kenya, Ethiopia, Somalia, Djibouti[ 124 - 126 ]. In Ethiopia, a study carried out among academic staff of a university revealed that the lifetime prevalence of Kath chewing was 41%[ 126 ], while another study carried out among college students reported a prevalence of 42%[ 124 ]. In Kenya, a recent household survey revealed that the prevalence of current Kath chewing in the region was 36.8%[ 125 ], which would suggest a significant rise from the 20% prevalence reported by the World Health Organization[ 123 ]. While Kath chewing was not previously known outside the regions within which it was cultivated, the effects of migration and trade have propelled it to a widely used psychostimulant globally[ 115 , 127 ]. Kath chewing has been associated with adverse health effects that is creating public health challenges in countries across Asia, Europe, Australia, and the United States of America[ 128 - 130 ]. When chewed concurrently with tobacco, there have been reports of cardiovascular stress response[ 129 ]. It has also been associated with the alteration of physical, mental, social and cognitive aspects of human functioning[ 131 ]. Chewing Kath chronically has been reported to cause memory impairment, sleeping disorders, liver toxicity, cardiovascular disease, psychosis and poor academic performance[ 126 , 132 ]. While attempts are being made by countries to criminalize the importation and trade of Kath, smugglers continue to find new avenues and trade routes. For example, in 2016, the National Drug Law Enforcement Agency of Nigeria reported seizures of Kath load, which was possibly destined for the Nigerian market or enroute countries[ 133 ]. However, in 2020, the United States customs reported seizure of Kath load from Nigeria destined for the United States suggesting that Nigeria is fast becoming a Kath transit hub[ 134 ]. In Nigeria, complicating the substance abuse epidemic is the emerging trend of experimenting with plant extracts or brews from a group of flowering plants belonging to the Datura specie, of the nightshade family Solanaceae[ 135 , 136 ]. Although members of the Datura specie which are broadly known as thorn apple, devil’s apple, devil’s trumpet or angel’s trumpet have their origin in central Americas and in the south-west region of the United States if America[ 137 , 138 ], they have become naturalized all over the world, being widespread in Asia, Europe, and Africa[ 139 ]. The datura specie is made up of herbs and shrubs with erect or branched stems, with alternate simple basal leaves and opposite leaves on terminal branches[ 139 ]. The fruit has a spiny capsule and reniform seeds[ 139 , 140 ]. All parts of the Datura stramonium and Datura metal plant has been shown to contain tropane alkaloids such as atropine, scopolamine, and hyoscyamine which have significant anticholinergic and hallucinogenic activity[ 141 ]. The high tropane alkaloid content of these plants increases their medicinal value and also opens them up to potential abuse. In Nigeria, Datura stramonium (thorn apple, devil’s snare, devil’s trumpet or jimsonweed) and Datura metal (Indian thorn apple) are naturalized. Similar to a number of countries across the world (United States of America and Canada) where there has been reports of datura-induced poisoning among adolescents who abuse the plant for its hallucinogenic effects[ 142 - 144 ], adolescents and young adults in Nigeria are also experimenting with the plant and getting poisoned[ 136 ]. Datura metal grows wildly (although at times it is cultivated) across the different regions of Nigeria where it is called ‘Myaramuo’ by the Igbos of south eastern Nigeria, ‘Zakami’ by Hausas of northern Nigeria and ‘Apikan’ by the Yorubas of southwestern Nigeria[ 145 , 146 ]. Datura stramonium also grows as a weed and is also cultivated across the different states of Nigeria. It is known as ‘Gegemu’ by the Yorubas and ‘Zakami’ by the Hausas[ 136 ]. Both plants have been reported to have hallucinogenic and euphoric effects when the different parts of the plant are either smoked or used to make concoctions[ 147 ]. Datura stramonium poisoning is associated with hyperthermia, tachycardia, delirium, pronounced amnesia, severe mydriasis, bizarre behaviors and painful photophobia[ 136 , 148 ]. These features can appear as early as 30 min to 1 h following consumption of the extract or smoking of the weed and have been reported to last several hours to days or at times even as long as 2 wk[ 148 ]. Another plant with psychoactive properties is the Western African shrub Tabernanthe iboga from whose root bark ibogaine, a hallucinogenic alkaloid is extracted. Traditionally, the concoctions from the roots have been used for their stimulatory, hallucinogenic, and sedative effects[ 149 ]. Ibogaine has been reported to exhibit stimulant effects at low doses and result in the development of hallucinations at high doses. Its use has also been associated with the development of ataxia, tremor, cardiac toxicity, and death[ 149 - 151 ]. There have also been reports that ibogaine has anti-addictive properties, although its use is limited by its deleterious effects[ 152 , 153 ]. In southern Africa, the use of extracts, dried-powdered herb, tincture, tea bags and seeds of the plant sceletium tortuosum also known as Kanna is also gaining traction. These different compositions of the plant can be chewed, smoked, snorted or swallowed resulting in increased libido, decreased stress, euphoria and appetite suppression. There are reports attributing the antidepressant and mood-elevating effects of the plant to the serotoninergic activity of its alkaloids including mesembrenone, mesembrenol, mesembrine, and tortuosamine. Indiscriminate use has been associated with the development of anxiety, headache, hypertension, irritability, insomnia and nausea[ 154 , 155 ]. A serotonin syndrome has also been observed especially when consumed alongside selective serotonin reuptake inhibitors or monoamine oxidase inhibitors. Although the use of a number of these plants and herbs may not be illegal in the countries in which they are consumed, increasing reports of poisoning arising from the use or these psychoactive plants solely or in combination with other compounds is drawing attention to the need to enact public health laws that can criminalize their use. Synthetic cannabinoid in herbal products Synthetic cannabinoids are compounds which are structurally similar to natural cannabinoids [tetrahydrocannabinol and cannabidiol ( CBD)] allowing them to exert their effect through binding to cannabinoid receptors (CBD1 and CBD2)[ 156 , 157 ]. Synthetic cannabinoids can be agonists at the CB 1 receptors or antagonists at other cannabinoid receptors. Although many of the synthetic cannabinoids are used in pharmacology in structure - activity relationships and receptor binding studies, others have medicinal uses including in the treatment of anorexia, as antiemetics in cancer chemotherapy and in pain management. In the last two decades, commercial preparations containing synthetic cannabinoids have become popular for their use as designer drugs marketed as herbal incense or herbal blends under the names ‘Spice’, ‘synthetic marijuana’, and ‘K2’[ 158 - 160 ]. The cannabinoid compound is sprayed onto inert plant material and smoked or ingested in liquid form[ 160 , 161 ]. Although often considered legal and safe alternatives to cannabis, there is evidence indicating that synthetic cannabinoids use is associated with significant health risks when compared to marijuana; there have also been reports that their distinct pharmacological effects and metabolic activity could also be a contributing factor to the increased toxicity observed following their use[ 157 , 162 , 163 ]. To date, the abuse of herbal preparations that have been spiked with synthetic cannabinoids continues to increase. This is evidenced by an increasing list of commercial preparations marketed in the United States and Europe under the names fairly legal, Pandora’s box, Angry birds, exodus, bonzai, annihilation, weekend blend, fire, strong spice, green Buddha, smoke, and Scooby snacks[ 102 , 164 ]. In the last few years, Africa is also beginning to experience a surge in demand for and use of synthetic cannabinoids. In Mauritius, since the year 2015, there has been a reported increase the number of arrests involving synthetic cannabinoids[ 165 ]. In different countries in the continent they are marketed under various street names including, Wiz in South Africa[ 166 ]. In Nigeria it is marketed as Black Mamba, Colorado , Lamba, Happy Boy or Scooby Snax[ 167 ]. Across Africa, available evidence points to a growing use of novel psychoactive compounds which mainly contain synthetic cannabinoids. Synthetic cannabinoids have effects that are similar to that experienced with natural cannabis, although they are more potent and have been associated with more severe physical and psychological adverse effects necessitating hospitalizations[ 168 , 169 ]. PREVALENCE OF SUBSTANCE USE DISORDERS AND AVAILABILITY OF EVIDENCE-BASED TREATMENT CENTRES IN AFRICA Substance use disorders are defined as the persistent use of alcohol or other psychoactive substances despite significant harm and untoward health consequences[ 170 ]. They are characterized by an array of social, emotional and behavioral problems. Across Africa, there is also a dearth of scientific data on the prevalence of substance use disorders or drug dependence[ 48 , 55 , 56 , 171 ]. In Nigeria, reports from the 2018 National Drug Survey revealed that one in every five persons who used drug in the past year also had a drug-related disorder[ 48 , 55 , 56 ]. In South Africa, results obtained from a nationally representative sample of 4351 persons aged 18 years and above revealed a lifetime prevalence of substance use disorders of 13%, with alcohol use disorder being the most prevalent type of substance use disorders[ 72 , 171 - 173 ]. In Egypt, reports obtained from the National Addiction Research Study revealed the prevalence of drug dependence in the different regions ranged from 3.2%-9.3%[ 174 ]. Left untreated, substance use disorders contribute significantly to the global burden of disease, including increasing morbidity and mortality and societal cost implications such as increased healthcare costs, lost productivity and costs related to social welfare and criminal justice[ 4 , 5 ]. Access to evidence-based treatment has been linked with a reduction in the risk for ill health[ 171 ]. Accordingly, towards reducing the burden of substance use globally, availability and access to evidence-based treatment facility were included in the United Nations’ Sustainable Development Goals for 2030[ 175 ]. However, despite reports of increasing prevalence of drug dependence and substance use disorders, reports from surveys carried out in a number of countries in Africa suggest that the availability of treatment centers are limited[ 171 , 176 ]. Factors contributing to this treatment gap include treatment infrastructure constraints, poor funding, and the high cost of private-for-profit treatment centers[ 171 , 176 ]. How can Africa’s burgeoning substance use and substance use disorder problem be addressed It has become evident that there is a burgeoning illicit drug use problem across the African continent[ 47 - 49 , 177 ]. There had been predictions that by the year 2050, increased life expectancy and a rapidly growing population would result in approximately 130% increase in the burden of mental and substance use disorders to about 45 million years lived with disability in Africa[ 178 ]. While different factors, including increased access to illicit drugs and high level of youth unemployment have been adduced to explain the emerging drug use pandemic; its significant contribution to economic instability, crime, criminality and insecurity across Africa and worldwide means that governments and policy makers need to prioritize the need to develop ways to mitigate these problems. The dearth of comprehensive data and the uniqueness of the manifestation of illicit drug use to individual countries within the African region are factors that impede progress towards addressing this looming pandemic. Understanding the different determinants of drug use within the different populations of Africans and how these impact the prevention and treatment of substance abuse disorders in the individual countries would be an important step towards addressing this emerging pandemic. Currently available data suggests that influencers of drug use (particularly in adolescents) which include family, social networks and peer pressure are common to most of the countries[ 179 - 184 ]. Other determinants of drug use also include childhood trauma and adverse life experiences such as sexual, emotional or physical abuse. Across age groups, demographic factors such as being male, lower level of education and attendance of private schools have also been reported by researchers from the different regions of Africa[ 185 - 187 ]. In addition to understanding the influencers and determinants of drug use, there is also a need for up-to-date national and regional data that can adequately determine the prevalence and incidence of drug use across all demographics. The availability of a detailed and comprehensive national data would provide a background against which policy successes or failures can be measured, it would also alert governments and international partners on the need for increased funding or more treatment facilities. The deleterious health effects of drug use disorders means that the provision of effective prevention, treatment and care facilities for substance use disorders is a necessary investment in the health of the society as a whole. Research has shown that the availability of evidence based prevention programs and policies have the ability to significantly reduce substance use and related harmful effects[ 188 ]. Behavioral and medication-assisted treatment using a chronic-illness-management approach has also been shown to aid recovery and prevent relapse. There have been suggestions that easy access to support services assist previous substance users to achieve and maintain wellness long-term[ 188 ]. Addressing the ease of access to drugs and other illicit substances within communities and regions need to be taken more seriously. There is a need to gather information on the different types of novel psychoactive substances that are available within communities and also create awareness as to the adverse health effects associated with consuming these compounds. Limitations and recommendations One of the major limitations encountered in this review was the dearth of recent, community based and age specific scientific data on the prevalence and extent of the substance abuse problems in most of the countries in Africa. There was also a deficit of data on the details and impact of the country-specific intervention protocols. This led to reliance mainly on third party data from international; partners and a few independent researchers. The battle to win this emerging substance–use pandemic in Africa can only be successful if there is increased emphasis in documenting the extent of the problem and country specific interventions; particularly at the community levels with emphasis on how different age groups are impacted by substance abuse. In Africa, substance use and substance use disorders drain struggling economies and health care systems. While the continent might have some general idea of what it is up against, understanding the details of the problem and availability of the willpower/wherewithal to subdue it remains a challenge. It is becoming obvious that there is no substitute for well-designed, accurate and comprehensive population-focused efforts at obtaining data that relates to substance use and substance use disorders, since such data will form the foundations for designing effective intervention strategies. Also, in Africa, interventional strategies should place emphasis on prevention, through identification of and mitigation of risk factors, as this approach is likely to consume less resources in the long run. Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article. Provenance and peer review: Invited article; Externally peer reviewed. Peer-review model: Single blind Peer-review started: March 4, 2022 First decision: April 18, 2022 Article in press: September 7, 2022 Specialty type: Psychiatry Country/Territory of origin: Nigeria Peer-review report’s scientific quality classification Grade A (Excellent): 0 Grade B (Very good): B, B, B Grade C (Good): C Grade D (Fair): 0 Grade E (Poor): 0 P-Reviewer: Kar SK, India; Liu XQ, China; Setiawati Y, Indonesia S-Editor: Wang JJ L-Editor: Filipodia P-Editor: Wang JJ Contributor Information Olakunle James Onaolapo, Behavioral Neuroscience Unit, Neuropharmacology Subdivision, Department of Pharmacology, Ladoke Akintola University of Technology, Ogbomoso 210214 Oyo, Nigeria. Anthony Tope Olofinnade, Department of Pharmacology, Therapeutics and Toxicology, Lagos State University, Ikeja 100001, Lagos, Nigeria. Foluso Olamide Ojo, Department of Anatomy, Ladoke Akintola University of Technology, Ogbomoso 210214, Oyo, Nigeria. Olufunto Adeleye, Department of Anatomy, Ladoke Akintola University of Technology, Ogbomoso 210214, Oyo, Nigeria. Joshua Falade, Department of Mental Health, Afe Babalola University, Ado-Ekiti 360282, Ekiti, Nigeria. Adejoke Yetunde Onaolapo, Behavioral Neuroscience Unit, Neurobiology Subdivision, Department of Anatomy, Ladoke Akintola University of Technology, Ogbomoso 210214, Oyo, Nigeria. moc.oohay@yibiyabgeda . < Back to my filtered results Drug use and alcohol consumption among secondary school learners in Gauteng This research report focuses on the extent and impact of substance use and abuse among high school learners in Gauteng. The research results presented in this report were collected from randomly selected secondary schools in Gauteng, where 4,346 learners completed self-administered paper-based questionnaires during school time, in the presence of teachers and trained Youth Research Unit staff members. The research findings show that drug and alcohol abuse among young people is a reality with concerning consequences. Not only do young people find themselves in an environment in which drugs and alcohol are readily accessible, but very often these substances are used by their peers, to whom they relate and with whom they interact. Hence, their receptiveness to drug and alcohol use increases. Despite a general increase in cigarette smoking and the use of hubbly bubblies among young people, the research findings show the most common illicit drug used among learners, mainly for enjoyment and stress relief, is cannabis (dagga). A few learners reported the use of drugs to enhance performance at school, which clearly demonstrates the stress these learners experience and a desperate need for enhanced performance. It is noteworthy that learners often use drugs at home and school, both environments with a significant adult presence. A review of Literature on Drug and Substance Abuse amongst Youth and Young Women in South Africa - Soul City Institute Download HTML Download PDF Health & Fitness IT & Technique Government & Politics Food & Drink Uncategorized Home & Garden Arts & Entertainment Style & Fashion Current Events Hobbies & Interests 131 IMAGES (PDF) Substance abuse among high school learners in a rural education Literature review on effects of drug abuse Introducing substance use and abuse in SA brain behaviour and other (PDF) Substance Abuse among High School Learners in South Africa: A (PDF) Mapping and analyzing the scientific literature on drug abuse Problem of Drug Abuse in Schools COMMENTS (PDF) Substance Abuse among High School Learners in South Africa: A In 2004, substances such as 'nyaope' or 'kat aza' or 'whoonga' were. identified as common drugs abused by learners in several South African. schools in the township (Mamabolo, 2020). According to ... Substance abuse among high school learners in a rural education Introduction. South Africa has a high rate of substance abuse among young people, which includes both in and out of school youth. Despite reported stigma and associated reluctance to seek treatment for substance abuse, 1 an increase in young people aged 20 years seeking treatment for substance abuse, 2 is an indication of the gravity of the problem. . Variations in the trends of substance use ... (PDF) Substance Abuse among High School Learners in South Africa: A PDF | On Apr 5, 2021, M.V. Nzama and others published Substance Abuse among High School Learners in South Africa: A Case Study of Promoting Factors African Journal of Development Studies (AJDS ... Trends in socio-demographic characteristics and substance use among Substance use is an escalating public health problem in South Africa resulting in risky behaviours and poor educational attainment among adolescents. There is a huge battle to overcome substance use among learners as more drugs become easily available with the mean age of drug experimentation reported to be at 12 years of age. It is important to continuously understand the trends in substance ... Substance use amongst secondary school students in a rural setting in Meanwhile, from a survey conducted in South Africa in 2008 amongst young people of age 13 to 22 years, the rate of cannabis abuse was 12.7%, whilst in the USA cannabis usage by grade 10 pupils in 2010 was 33.4%. 7. In South Africa, substance abuse is extremely serious, with drug usage reported as being at twice the world norm. Prevalence and correlates of substance use among school-going Prevalence of substance use among adolescents in Africa. Results from Fig. 1 showed that the overall prevalence rates of substance use among school-going adolescents in SSA were 11.3%, 2% and 2.6% for current alcohol use, marijuana use and amphetamine use, respectively. Current alcohol use was highest in Seychelles (46.5%) and lowest in Tanzania (2.7%). Substance use amongst high school learners in the south of Johannesburg Introduction. The use of psychoactive substances by adolescents at school is a major global public health problem. 1,2 The prevalence of substance abuse has been reported to be on the rise in countries throughout the world such as Iran and Brazil and also in some African countries such as Nigeria, Ghana and Ethiopia. 3,4,5 Because adolescence is a period of risk-taking, young people often ... Substance abuse among high school learners in a rural education Maupa MA, Obioha EE. Contemporary contributory factors of youth drug abuse in Gauteng, South Africa. Int J Soc Sci Humanity Stud. 2017;9(1):170-185. Lawal AS, Marafa B. Management of students' discipline in a drug and substance abuse-laden school environment. In: Erçetin ŞŞ, editor. Chaos, complexity and leadership 2014-2016. Substance use by adolescents in Cape Town: prevalence and ... Purpose: The work reported in this paper was supported by grants from the World Health Organisation Programme on Substance Abuse, the United Nations Development Programme, the South African Medical Research Council, and the Medical Faculty Research Committee of the University of Cape Town.To document the prevalence rates for use of cigarettes, alcohol, and cannabis among high school students ... The National Policy of Drug Abuse Management in Schools in South Africa The results of a study by Mokwena et al. (2020), drawn from members of school management teams in schools in North West province, South Africa, revealed that the National Policy of Drug Abuse ... PDF Intoxicated in the classroom: Teachers' experiences of teaching drug literature on drug abuse in schools. LITERATURE REVIEW The United Nations 2030 Agenda for Sustainable Development, with its 17 goals and 169 targets, is considered to be a universal policy agenda that provides a plan of action for people, planet, and prosperity (UN, 2015). South Africa is a signatory of the Sustainable Development Goals Alcohol and drug use as factors for high-school learners' absenteeism In a cohort of 1259 and 1076 grade 9 learners, alcohol consumption was associated with poor academic performance and absenteeism in KZN, South Africa. 7 Heradstveit et al. 8 studied the association amongst alcohol, drug use and a low-grade point average (GPA) and school attendance in Norway. They utilised registry-based data on school-related ... Drug abuse by learners in South Africa: a replication and extension Abstract. This study sought to determine the nature, extent and causes of drug abuse in South African township schools. Interview data were collected from a convenience sample of 24 participants from 4 schools (10 learners, 8 school personnel and 4 School Governing Board (SGB) members, a social worker and one Department of Education (DoE) official responsible for handling drug abuse by ... PDF Factors Associated With Illegal Drug Use in South Africa: a Qualitative Abstract. This study provides a comprehensive literature review of the recent peer-review and journal articles pertaining to illegal drug use in South Africa. Potential articles pertaining to South African illicit drug use published between 1994 and April 2019 were identified through an exhaustive literature pursuit. Substance use and substance use disorders in Africa: An epidemiological South Africa: School-based survey: Secondary school students: 13% of the students (aged 19 yr and below) had an history of cannabis use, although current use was 9%. 12% had a current use of heroin, 11% used inhalants and 6% consumed mandrax ... A review of literature on drug use in Sub-Saharan Africa countries and its economic and social ... Drug use and alcohol consumption among secondary school ... This research report focuses on the extent and impact of substance use and abuse among high school learners in Gauteng. The research results presented in this report were collected from randomly selected secondary schools in Gauteng, where 4,346 learners completed self-administered paper-based questionnaires during school time, in the presence of teachers and trained Youth Research Unit staff ... Substance use amongst secondary school students in a rural setting in The substance abuse section was reviewed and emphasised in order to address the issue of drug abuse problem within South Africa. In addition, the department also established a 'Policy Framework for the Management of Drug Abuse by Learners in Schools and Further Education and Training Institutions' so as to serve as a guide to all schools in ... A review of Literature on Drug and Substance Abuse amongst Youth and Section 1 Introduction Substance abuse is a global challenge with detrimental effects on health, wealth and security of nations (UNODC, 2010). In South Africa drug abuse has been associated with crime, interpersonal violence, risky sexual behaviour (with accompanied increased risk of HIV acquisition and STI incidences), negative health of users and negative psychological impact to their families. Intoxicated in the classroom: Teachers' experiences of teaching drug The number of drug users in Africa is projected to rise in the next decade by as much as 40 per cent, simply because of the growing youth population on the continent (UNODC,2021). Literature Review Of Drug Abuse In South Africa A study by Nesser (2005) revealed that over 42 per cent of young people in South Africa had seen drugs being sold in their neighborhoods. The same study revealed that when young people were asked if whether they knew a friend or classmate who was using illegal drugs, the majority of coloured (79.3 percent) confirmed that they did. (PDF) Substance Abuse: A Literature Review of the ... Substance or Drug abuse is a serious public health problem affecting usually adolescents and young adults. It affects both males and females and it is. the major source of crimes in youth and ... Vulnerable Learners' Experiences on Drug Abuse in Zimbabwean Rural 80 East African Journal of Education and Social Sciences (EAJESS) 2(2)80-86 Vulnerable Learners' Experiences on Drug Abuse in Zimbabwean Rural Schools: A Literature Review Perspective Munyaradzi Chidarikire, PhD1* Pinias Chikuvadze, PhD2 and Cecilia Muza3 1Bindura University Science Education, Zimbabwe 2University of Free State, South Africa 3Great Zimbabwe University, Zimbabwe assignment essay homework paper phd report review speech thesis