Our study found that reported (ever, last 12 months and last 30 days) alcohol use was common amongst undergraduate health sciences students in Johannesburg, South Africa. Similarly, we further found a high prevalence of monthly heavy episodic drinking (> 6 standard drinks of alcohol) and AUD. The reported alcohol use and AUD rates were higher compared to previous studies conducted among college students in other provinces (8, 22).
Among college students, race was associated with alcohol use and AUD – that was similar to previous reports by Young and de Klerk, 2008 (7, 17) and Peltzer and Ramlagan, 2009 (7). Our study showed that the male gender was associated with alcohol use and AUD and this is not different from previous studies among college students that reported high rates of harmful and hazardous alcohol use among males (8, 23). Disposable income increases access to alcohol use, as such students reporting an income higher than the median for the group had higher odds of reporting alcohol use – similar to previous work among students in South Africa (7, 8, 24).
This study underscores the importance of parenting and siblings on alcohol use at the family level. As such having a sibling and parents who used alcohol was associated with high odds of reporting alcohol use (5, 8, 17, 25–27) and that could be explained by the social learning process in which children of parents who adopt norms favourable to alcohol use imitate their parents, as such behaviours are seen as normative to the children, subsequently socially reinforced, and are thus also adopted by them (28). However, Mahedy et. al., 2018 found an indirect effect between parental alcohol use and children’s alcohol use in adulthood through the mediators associating with deviant peers and early alcohol initiation (29). Due to the strong ties shared by siblings, and their role model effect, siblings exert their influence for alcohol use mainly through the peer domain. They may also act as alcohol use advocacy agents thus not only encouraging and approving its use, but also supplying the alcohol to their siblings(28).
Exposure to alcohol in the media (including social media) in the past 7 days, especially always/daily, carried greater risk for ongoing and risky alcohol use as it was associated with use in the past month, and AUD. This influence by the alcohol industry on risky drinking is evident in previous studies by Young and de Klerk, 2008 (17) and Francis et al., 2014 (5). Similarly, Engels et. al., 2009 found that watching a movie that portrays scenes of alcohol use led study participants to drink higher levels of alcohol while watching the movie – with those exposed to such scenes drinking an average of 1.5 glasses more than individuals not exposed to such scenes whether in movies or commercials (30). A systematic review and study by Gupta. et. al., 2016 & Gupta et. al., 2018 also supports the finding that being exposed to alcohol-related content through the internet was associated with individuals’ alcohol use (31, 32). The term to describe this effect is “cultures of intoxication” in which such exposure creates an active pathway that promotes alcohol use and risky drinking with positivity resulting in such behaviours by the viewer (31).
The effect of religiosity on alcohol use in high school students has been previously established – it was found that an inverse relationship between learners with high religiosity levels and the use of alcohol in the last 30 days existed (33). Being a member of the Moslem religion was associated with greatly reduced odds of “ever use” of alcohol and use in the past 12 months. These results are supported by previous studies that found similar results. One study found that being Muslim was negatively associated with alcohol use, specifically in adolescent boys(12). This reflects a subculture that promotes abstinence from alcohol use through strictly forbidding the use of alcohol within the religion – which is achieved by Muslims communicating more explicit messages regarding alcohol. This contributes to the spiritual convictions regarding their stance on alcohol use, encouraging them to drink less or even none at all (10).
One-on-one physical sessions with a healthcare professional was the most acceptable modality through which to receive alcohol and other health-related interventions, followed by cellular communications through WhatsApp or mobile phone Short Messages (SMS). A study by Johannson et. el., 2021 also found that the preferred mode of intervention was the face-to-face one, with more participants engaging in this mode than the internet-based ones (15). Contrary to this, other studies found that the most common and preferred intervention for AUD were online therapy programmes such as Screening, Brief Intervention, and Referral to Treatment (14, 34). This offers insight to potential platforms of delivery in the implementation of health promotion or therapeutic interventions such as digital therapeutics.
The findings of this study should be interpreted in light of the potential limitations. First, a selection bias because of non-response and incomplete surveys, however, a sensitivity analysis, showed that there was minimal difference between participants who completed the surveys and those who did not. There was no notable difference between respondents and non-respondents among all the population characteristics except or ‘living situation’ – where those living alone were significantly less likely to respond to the survey. These findings are supported a previous study that also found that individuals living alone were less likely to participate in their surveys (35). Second, social desirability bias due to self-reporting of alcohol outcomes, however, this bias was largely reduced by anonymous and self-administration of the surveys. Third, part of the study was conducted during the 2020 COVID-19 pandemic lockdown, during which the alcohol sales were restricted this may have led to low reported alcohol use in the last 30 days. Last, the findings could only be generalized to health sciences university students in Johannesburg, South Africa