Risk factors of alcohol problem drinking among female bar/hotel workers in Moshi, Tanzania: a multi-level analysis

Epidemiology of alcohol use and alcohol use disorder among female sex workers in Mbeya City, Tanzania

Alcohol misuse is a global concern, contributing to 5.3% of total deaths and 132.6 million disability-adjusted life years worldwide. In Sub-Saharan African countries, the prevalence of Alcohol Use Disorder (AUD) has risen, especially among female sex workers, due to increased availability and advertising. However, there are limited studies on alcohol use and AUD among female sex workers in Tanzania. This study aimed to determine the prevalence, patterns, and factors associated with alcohol use and AUD among sex workers in Mbeya city, Tanzania. In this cross-sectional study, 212 female sex workers in Mbeya city, Tanzania, seeking enrolment in the National Institute for Medical Research Mbeya Medical Research Centre's registration cohort from July to November 2022. Structured interviews covered socio-demographics, alcohol screening (AUDIT-C and Timeline Follow Back Calendar), and sexual behaviours data. Data were analysed using Stata version 17. Descriptive analysis assessed alcohol consumption and AUD prevalence. Factors associated with alcohol use and AUD at bivariate analysis were identified using Chi-square/Fisher's exact tests. All variables with p-value ≤ 0.20 were entered into a multivariable logistic regression model to identify factors associated with alcohol use and AUD. Among 212 participants, 86.6% reported alcohol use in the past 12 months, 85% in the past 30 days, and 98.5% met AUD criteria. Factors linked to recent alcohol consumption included primary education or higher, income above the median, and more than 10 sexual partners. Education level, marital status, income, and having dependents were significantly associated with heavy drinking episodes. The prevalence of AUD, alcohol use, and heavy episodic drinking were high among female sex workers in Mbeya city. Socio-demographic factors and risky sexual behaviours were associated with alcohol use and heavy episodic drinking highlighting the need for targeted interventions to combat alcohol abuse among female sex workers within the HIV program.

Clinical evaluation of the alcohol use disorders identification test (AUDIT) in Moshi, Tanzania

BACKGROUND

Alcohol use disorder is a major cause of morbidity and mortality in low- and middle-income countries. Alcohol screening using a validated tool is a useful way to capture high-risk patients and engage them in early harm reduction interventions. Our objectives were to 1) evaluate the psychometric evidence the Alcohol Use Disorders Identification Test (AUDIT) and its subscales in the general population of Moshi, Tanzania, and 2) evaluate the usefulness of the tool at predicting alcohol-related harms.

METHODS

Two hundred and fifty-nine adults living in Moshi, Tanzania were included in the study. We used the AUDIT and its subscales to determine the classification of harmful and hazardous drinking. To analyze the internal structure of AUDIT and the model adequacy we used Confirmatory Factor Analysis (CFA). The reliability of AUDIT was analyzed for Cronbach's alpha, Omega 6 and Composite Reliability. The optimal cut off point for the AUDIT was determined by the receiver operating characteristic (ROC) curve, using the Youden approach to maximize sensitivity and specificity.

RESULTS

The median score of the AUDIT was 1 (inter-quartile range: 0-7). The internal structure of the AUDIT showed factor loadings ranging from 0.420 to 0.873. Cronbach's alpha, Omega and Composite Reliability produced values above 0.70. The Average Variance Extracted was 0.530. For the AUDIT, a score of 8 was identified as the ideal cut-off value in our population.

CONCLUSIONS

This study validates AUDIT in the general population of Moshi and is one of the only studies in Africa to include measures of the internal structure of the AUDIT and its subscales.

Perceptions of alcohol use among injury patients and their family members in Tanzanian society

Alcohol is one of the leading causes of death and disability worldwide. Rates of alcohol abuse in Moshi, Tanzania, are about 2.5 times higher than the Tanzanian average. We sought to qualitatively assess the perceptions of alcohol use among injury patients in Moshi, including availability, consumption patterns, abuse, and treatments. Participants were Emergency Department injury patients, their families, and community advisory board members. Participants were included if they were ≥18 years of age, a patient or patient's family member seeking care at the Kilimanjaro Christian Medical Center Emergency Department, Moshi, Tanzania, for an acute injury, clinically sober at the time of enrollment, medically stable, able to communicate in Swahili and consented to participate. Focus group discussions were audiotaped, transcribed, translated, and analyzed in parallel using an inductive thematic content analysis approach. Resultant themes were then reanalyzed to ensure internal homogeneity and external heterogeneity. Fourteen focus group discussions, with a total of 104 participants (40 patients, 50 family members, 14 community advisory board members), were conducted. Major themes resulting from the analysis included: 1) Early/repeated exposure; 2) Moderate use as a social norm with positive attributes; 3) Complications of abuse are widely stigmatized; and 4) Limited knowledge of availability of treatment. Our findings suggest that, among our unique injury population and their families, despite the normalization of alcohol-related behaviors, there is strong stigma toward complications stemming from excess alcohol use. Overall, resources for alcohol treatment and cessation, although broadly desired, are unknown to the injury population.

Maternal role strain and depressive symptoms among female sex workers in Mexico: the moderating role of sex work venue

Stressors that arise in parenting are likely to have an adverse impact on the psychological well-being of female sex workers (FSWs), particularly in low- to middle-income countries (LMIC). This study examined the association between maternal role strain and depressive symptoms among 426 FSW mothers with dependent-age children (aged < 18 years) in Tijuana and Cd. Juarez, Mexico (2016-2017). Four dimensions of maternal role strain (e.g., child emotional and behavioral problems) were examined in relation to maternal depressive symptoms. We also investigated whether the relationship between maternal role strain and depressive symptoms was modified by venue of sex work. Compared to indoor/establishment-based FSWs, street-based FSWs reported significantly more child-related financial strain. In multiple regression analysis, having more depressive symptoms was associated with identifying as a street-based FSW, greater use of drugs, lower emotional support, more child-related financial strain and more emotional and behavioral problems in children. A significant interaction was identified such that the association between maternal role strain and depressive symptoms was stronger for indoor/establishment-based compared to street-based FSWs. These findings suggest the need to address parenting strain and type of sex work venue in the development of counseling programs to improve the mental health of FSWs in LMIC.

Cross-Culture Adaptation and Psychometric Properties of the DrInC Questionnaire in Tanzanian Swahili

Aims: To develop Swahili versions of the Drinker Inventory of Consequences (DrInC) and evaluate its psychometric properties among a mixed population in Tanzania.

Methods: A Swahili version of the DrInC was developed by a panel of bilingual Swahili and English speakers through translation and back-translation. The translated DrInC was administered to a sample of Tanzanian injury patients and a sample of the general population. The validity and reliability of the scale were tested using standard statistical methods.

Results: The translated version of the DrInC questionnaire was found to have outstanding domain coherence and language clarity. The tested scale and subscales have adequate reliability (>0.85). Confirmatory factor analysis (CFA) confirmed the five-factor solution by yielding adequate results. DrInC score is statistically significantly correlated with alcohol consumption quantity and the AUDIT score, suggesting that DrInC is able to predict alcohol use as well.

Conclusions: This study presents the first validation of the DrInC questionnaire with injury patients and a general population and the first adaptations of the DrInC questionnaire in the Tanzanian and Swahili setting. DrInC instrument was found to have satisfactory psychometric properties, resulting in a new medical and social research tool in this setting.

Perceived barriers by health care providers for screening and management of excessive alcohol use in an emergency department of a low-income country

Annually, alcohol causes 3.3 million deaths; countless more alcohol-related injury patients are treated in emergency departments (EDs) worldwide. Studies show that alcohol-related injury patients reduce their at-risk alcohol-use behavior with a brief negotiational interview (BNI) in the ED. This project aims to identify potential perceived barriers to implementing a BNI in Tanzania. A knowledge, attitude, and practice questionnaire was piloted and administered to all emergency department health care practitioners, including physicians, advanced medical officers, and nurses. The questionnaire included the Perceived Alcohol Stigma (PAS) Scale. The survey was self-administered in English, the language of health care instruction, with a Swahili translation available if preferred. Data were analyzed with relative and absolute frequencies and Spearman's correlation. Thirty-four (100%) health care practitioners completed the survey. Our results found positive attitudes toward addressing alcohol misuse (88%), but very poor knowledge of recommended alcohol-use limits (24%). Participants were willing to discuss alcohol use (88%) and to screen (71%) for alcohol-use disorders. Most health care practitioners report significant stigma against those with alcohol-use disorders (39% discrimination, 53% devaluation, 71% either). Counseling patients about high-risk alcohol use was directly and positively associated with at-risk alcohol and counseling education and believing it was common to ask patients about tobacco and alcohol use; it was negatively associated with believing it was 'not my role' or that knowing about alcohol use 'won't make a difference'. Stigma was negatively and indirectly associated with counseling patients. In conclusion, in an ED in Tanzania, health care practitioners have positive attitudes toward addressing at-risk alcohol use, and endorsed having training in alcohol misuse in school. Unfortunately, participants did not demonstrate knowledge of recommended alcohol limit guidelines. Similarly, among practitioners, there is a significant discrimination and devaluation stigma against those who misuse alcohol. These factors must be addressed prior to a successful implementation of an alcohol harm reduction intervention.

Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population

Aims

To develop Swahili versions of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaires and evaluate their psychometric properties in a traumatic brain injury (TBI) population in Tanzania.

Methods

Swahili versions of the AUDIT and CAGE were developed through translation and back-translation by a panel of native speakers of both English and Swahili. The translated instruments were administered to a sample of Tanzanian adults from a TBI registry. The validity and reliability were analyzed using standard statistical methods.

Results

The translated versions of both the AUDIT and CAGE questionnaires were found to have excellent language clarity and domain coherence. Reliability was acceptable (>0.85) for all tested versions. Confirmatory factor analysis of one, two and three factor solution for the AUDIT and one factor solution for the CAGE showed adequate results. AUDIT and CAGE scores were strongly correlated to each other (R > 0.80), and AUDIT scores were significantly lower in non-drinkers compared to drinkers.

Conclusions

This article presents the first Swahili and Tanzanian adaptations of the AUDIT and CAGE instruments as well as the first validation of these questionnaires with TBI patients. Both instruments were found to have acceptable psychometric properties, resulting in two new useful tools for medical and social research in this setting.

High Levels of Persistent Problem Drinking in Women at High Risk for HIV in Kampala, Uganda: A Prospective Cohort Study

The aim of this study was to describe the epidemiology of problem drinking in a cohort of women at high-risk of HIV in Kampala, Uganda. Overall, 1027 women at high risk of HIV infection were followed from 2008 to 2013. The CAGE and AUDIT questionnaires were used to identify problem drinkers in the cohort. Interviewer-administered questionnaires were used to ascertain socio-demographic and behavioural factors. Blood and genital samples were tested for HIV and other sexually transmitted infections. At enrollment, most women (71%) reported using alcohol at least weekly and about a third reported having drunk alcohol daily for at least 2 weeks during the past 3 months. Over half (56%) were problem drinkers by CAGE at enrollment, and this was independently associated with vulnerability (being divorced/separated/widowed, less education, recruiting clients at bars/clubs, and forced sex at first sexual experience). Factors associated with problem drinking during follow-up included younger age, meeting clients in bars/clubs, number of clients, using drugs and HSV-2 infection. HIV prevalence was associated with drinking at enrollment, but not during follow-up. This longitudinal study found high levels of persistent problem drinking. Further research is needed to adapt and implement alcohol-focused interventions in vulnerable key populations in sub-Saharan Africa.

A qualitative study of discourses on heterosexual anal sexual practice among key, and general populations in Tanzania: implications for HIV prevention

Background

The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice.

Methods

This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software.

Results

Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. “Other” discourse involved participants’ perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex.

Conclusion

Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations.

Female sex workers' experiences with intended pregnancy and antenatal care services in southern Tanzania

Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in-depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub-Saharan Africa.

HIV-1 pol diversity among female bar and hotel workers in Northern Tanzania

A national ART program was launched in Tanzania in October 2004. Due to the existence of multiple HIV-1 subtypes and recombinant viruses co-circulating in Tanzania, it is important to monitor rates of drug resistance. The present study determined the prevalence of HIV-1 drug resistance mutations among ART-naive female bar and hotel workers, a high-risk population for HIV-1 infection in Moshi, Tanzania. A partial HIV-1 pol gene was analyzed by single-genome amplification and sequencing in 45 subjects (622 pol sequences total; median number of sequences per subject, 13; IQR 5-20) in samples collected in 2005. The prevalence of HIV-1 subtypes A1, C, and D, and inter-subtype recombinant viruses, was 36%, 29%, 9% and 27%, respectively. Thirteen different recombination patterns included D/A1/D, C/A1, A1/C/A1, A1/U/A1, C/U/A1, C/A1, U/D/U, D/A1/D, A1/C, A1/C, A2/C/A2, CRF10_CD/C/CRF10_CD and CRF35_AD/A1/CRF35_AD. CRF35_AD was identified in Tanzania for the first time. All recombinant viruses in this study were unique, suggesting ongoing recombination processes among circulating HIV-1 variants. The prevalence of multiple infections in this population was 16% (n = 7). Primary HIV-1 drug resistance mutations to RT inhibitors were identified in three (7%) subjects (K65R plus Y181C; N60D; and V106M). In some subjects, polymorphisms were observed at the RT positions 41, 69, 75, 98, 101, 179, 190, and 215. Secondary mutations associated with NNRTIs were observed at the RT positions 90 (7%) and 138 (6%). In the protease gene, three subjects (7%) had M46I/L mutations. All subjects in this study had HIV-1 subtype-specific natural polymorphisms at positions 36, 69, 89 and 93 that are associated with drug resistance in HIV-1 subtype B. These results suggested that HIV-1 drug resistance mutations and natural polymorphisms existed in this population before the initiation of the national ART program. With increasing use of ARV, these results highlight the importance of drug resistance monitoring in Tanzania.

Systematic review and meta-analysis: prevalence of alcohol use among young people in eastern Africa

Objective

Systematic review and meta-analysis of published studies of alcohol use among young people (age 15–24 years) in eastern Africa to estimate prevalence of alcohol use and determine the extent of use of standardised screening questionnaires in alcohol studies.

Methods

Five databases (MEDLINE, EMBASE, Global Health, Africa-wide, and PsycINFO) were searched for publications until 30th June 2013. Results were summarised using the guidelines on preferred reporting items for systematic reviews and meta-analyses (PRISMA) and on quality assessment using the modified quality assessment tool for systematic reviews of observational studies (QATSO). Heterogeneity was assessed using the I² statistic (DerSimonian-Laird).

Results

We identified 2785 potentially relevant studies, of which 56 were eligible for inclusion. Only two studies (4%) used the standardised Alcohol Use Disorder Identification Test (AUDIT) questionnaire, and six studies (13%) used the Cut down, Annoyed, Guilt, Eye opener (CAGE) questionnaire. The reported median prevalence of alcohol use was ever-use 52% [interquartile range (IQR): 20–58%], use in the last month 28% (IQR: 17–37%), use in the last year 26% (IQR: 22–32%), and problem drinking as defined by CAGE or AUDIT 15% (IQR: 3–36%). We observed high heterogeneity between studies, with the highest prevalence of ever use of alcohol among university students (82%; 95%CI: 79–85%) and female sex workers (66%; 95%CI: 58–74%). Current use was most prevalent among male sex workers (69%; 95%CI: 63–75%).

Conclusions

Reported alcohol use and problem drinking were common among diverse groups of young people in eastern Africa, indicating the urgent need for alcohol-focused interventions in this population. Few studies have used standardised alcohol screening questionnaires. Epidemiological research to investigate alcohol-focused interventions in young people should aim to apply such questionnaires that should be validated for use in this population.

Taxonomy of Caribbean tourism alcohol venues: implications for HIV transmission

BACKGROUND

Tourism areas represent ecologies of heightened HIV vulnerability characterized by a disproportionate concentration of alcohol venues. Limited research has explored how alcohol venues facilitate HIV transmission.

METHODS

We spatially mapped locations of alcohol venues in a Dominican tourism town and conducted a venue-based survey of key informants (n=135) focused on three facets of alcohol venues: structural features, type of patrons, and HIV risk behaviors. Using latent class analysis, we identified evidence-based typologies of alcohol venues for each of the three facets. Focused contrasts identified the co-occurrence of classes of structural features, classes of types of patrons, and classes of HIV risk behavior, thus elaborating the nature of high risk venues.

RESULTS

We identified three categories of venue structural features, three for venue patrons, and five for HIV risk behaviors. Analysis revealed that alcohol venues with the greatest structural risks (e.g. sex work on-site with lack of HIV prevention services) were most likely frequented by the venue patron category characterized by high population-mixing between locals and foreign tourists, who were in turn most likely to engage in the riskiest behaviors.

CONCLUSION

Our results highlight the stratification of venue patrons into groups who engage in behaviors of varying risk in structural settings that vary in risk. The convergence of high-risk patron groups in alcohol venues with the greatest structural risk suggests these locations have potential for HIV transmission. Policymakers and prevention scientists can use these methods and data to target HIV prevention resources to identified priority areas.

Frequent intra-subtype recombination among HIV-1 circulating in Tanzania

The study estimated the prevalence of HIV-1 intra-subtype recombinant variants among female bar and hotel workers in Tanzania. While intra-subtype recombination occurs in HIV-1, it is generally underestimated. HIV-1 env gp120 V1-C5 quasispecies from 45 subjects were generated by single-genome amplification and sequencing (median (IQR) of 38 (28–50) sequences per subject). Recombination analysis was performed using seven methods implemented within the recombination detection program version 3, RDP3. HIV-1 sequences were considered recombinant if recombination signals were detected by at least three methods with p-values of ≤0.05 after Bonferroni correction for multiple comparisons. HIV-1 in 38 (84%) subjects showed evidence for intra-subtype recombination including 22 with HIV-1 subtype A1, 13 with HIV-1 subtype C, and 3 with HIV-1 subtype D. The distribution of intra-patient recombination breakpoints suggested ongoing recombination and showed selective enrichment of recombinant variants in 23 (60%) subjects. The number of subjects with evidence of intra-subtype recombination increased from 29 (69%) to 36 (82%) over one year of follow-up, although the increase did not reach statistical significance. Adjustment for intra-subtype recombination is important for the analysis of multiplicity of HIV infection. This is the first report of high prevalence of intra-subtype recombination in the HIV/AIDS epidemic in Tanzania, a region where multiple HIV-1 subtypes co-circulate. HIV-1 intra-subtype recombination increases viral diversity and presents additional challenges for HIV-1 vaccine design.

Pro-alcohol-use social environment and alcohol use among female sex workers in China: beyond the effects of serving alcohol

The current study was designed to fill the literature gap by examining the roles of the pro-alcohol social environment in alcohol use among female sex workers (FSWs) in China. In this study, a total of 1,022 FSWs were recruited through community outreach from both alcohol-serving and nonalcohol-serving commercial sex venues in Guangxi, China. The pro-alcohol social environment was measured in four areas: institutional norms, institutional practices, risk perceptions and peer norms. The measures of the pro-alcohol social environment were significantly associated with the venues' alcohol-serving practices, with FSWs from those venues reporting a more positive pro-alcohol social environment than their counterparts from nonalcohol-serving venues. However, these pro-alcohol social environment measures were independently predictive of alcohol use after controlling for venues' alcoholserving practices and other demographic characteristics. Public health interventions need to target environmental-structural factors through altering pro-alcohol-use social norms and practices at both institutional and individual levels among FSWs in China.