Alcohol Availability, Marketing, and Sexual Health Risk Amongst Urban and Rural Youth in South Africa

This study of alcohol, youth and sexual health risk provides insight into the community context within which youth drinking takes place in rural and urban communities in South Africa. The results of the study provide substantial evidence that young people have easy access to alcohol in their communities. Facilitated by a combination of the high density of alcohol outlets, close proximity of outlets to schools and unrestricted entry to alcohol serving venues, this availability fuels early initiation and unsafe drinking and is in conflict with both WHO recommendations and South African legislation.

The South African 2003 Liquor Act and national liquor norms and standards stipulate that alcohol should not be sold to minors or children under the age of 18 years and that alcohol outlets should verify the age of its patrons, especially youth to ensure no sales to minors [30]. The proposed liquor laws stipulate that “liquor premises be located at least five hundred meters (500 m) away from schools, places of worship, recreational facilities residential areas and public institutions” [31]. Local and community-level advocacy is required to ensure compliance, including community-based monitoring processes. The study has shown how the environment influences youth drinking which commonly occurs below 18 years of age, and often involves binge drinking and forms a key element of youth recreation.

This study further highlights the efforts by the alcohol industry to reach youth through product formulation, advertising and other types of promotion. Young adults constitute a large proportion of the population in countries such as South Africa and are a lucrative potential market. A study conducted by the South African Medical Research Council in the Tshwane district has shown that young people are heavily exposed to alcohol marketing [32]. The WHO-sponsored study titled “Monitoring Alcohol Marketing Practices in Africa” (MAMPA) assessed alcohol marketing in four African countries and concluded that given the large volume of advertising on multiple platforms carrying strong themes of success and aspiration, alcohol advertising self-regulation which is already supposed to be in place is not effective [33].

Our study found that young women are specifically targeted through marketing approaches that include images of sophistication, happiness and attractiveness. This reflects an international trend where alcohol producers are increasingly targeting women by introducing new products designed for women as well as advertising and packaging that are appealing to women [34].The use of youth-friendly media, especially social media and music, further draw youth to alcohol products. This highlights the need for public education and media literacy to challenge the existing norms that advertisers use to attract youth to consume alcohol.

Our results further highlight the link between alcohol consumption and behaviors that increase the risk of HIV and sexual assault. Youth link alcohol consumption, which commonly occurs at taverns, to unplanned, unprotected and regretted sex, and sexual assault. This supports existing evidence by other researchers that suggest that there are a set of interlinking gender and drinking norms that support the processes that lead up to sexual risk associated with drinking [1, 9, 13]. Drinking spaces, particularly taverns, are perceived to be sites for both drinking in high volumes and meeting people with whom a sexual encounter is likely to take place that same evening [14, 15, 16, 17, 18]. Access to alcohol for young women is heightened through men purchasing them drinks, with an expectation of sex in return for the alcohol. Where drinks are bought by men, and accepted by women, there can be an expectation that the interaction will culminate in sex, with women giving up their right to refuse. The consequences for not consenting to sex could be severe, including rape [35].

An urban and a rural community were chosen to allow for comparison purposes in terms of the influence of alcohol as a structural driver for HIV and safety. Young people in both the rural and urban area generally perceived the issues of alcohol availability and marketing as a big problem in their communities. The differences were noted in the methods of promotional activities in communities, with billboards only found in the urban area while celebrity figures were often used for events in taverns in the rural area which resulted in youth attendance as that was the only opportunity for them to see the celebrities.

All alcohol outlets were within a 500 m radius to schools in the urban area while 79% of the outlets were within 500 m in the rural area. HIV prevention efforts addressing the risks of alcohol use need to also be tailored to alcohol drinking or selling places and where young people commonly gather to have entertainment including recreational parks “youth hang out spots”.

Poor lighting in the rural area was highlighted as a risk for young women to be sexually assaulted when going home while intoxicated from taverns. There appear to be several pathways leading to alcohol-related sexual assault. In addition to possible rape consequent to not consenting to sex after accepting drinks, rape while walking from a tavern as well as ‘incapacitated’ rape where the woman was too drunk to resist sex and/or was not sure if she had consented, were described. The link between alcohol consumption amongst women and sexual assault has been previously documented. Testa and Livingstone in a literature review concluded that drinking, particularly heavy episodic drinking, plays a significant role in a large proportion of sexual assault incidences amongst young women [36]. In South Africa, a study in the Eastern Cape found that alcohol was an important part of the context for gang rapes [37]. Male perpetrators also reported that women, at the time of being raped, were sometimes too drunk to stop them [38].

Key to a public health response to alcohol-related sexual risk and HIV prevention is the creation of safer drinking spaces, which has been advocated since 2010 by the Soul City Institute through the Phuza Wize campaign. The Phuza Wize campaign aimed to encourage safe drinking and reduce alcohol-fueled violence through training communities to create safer social drinking spaces using the 10 point criteria as recommended by the WHO. The campaign also had an advocacy focus that sought to influence policy formulation, government prioritization, and public discourse to protect communities from alcohol-related harm and violence in South Africa.

In South Africa, regulatory provisions could facilitate this through ensuring limited opening hours of alcohol outlets, separate toilets for men and women and provision of condoms at taverns [30]. Resources need to be allocated efficiently to ensure both increased public and tavern owner awareness of these provisions, coupled with training and support for their implementation. Promising interventions located at drinking venues need further evaluation and scale up. For example, Morojele and colleagues found that a peer-led safe sex program including conveying safe sex messages piloted in South Africa was well received and supported by bar patrons and servers while a brief community-based intervention including skills training for sexual negotiation and condom use led to safer sexual behaviors including a decrease in partners who met at a drinking establishment [14].

Despite the limitations, this study was the first in South Africa to explore, in depth young people’s perceptions and experiences of alcohol marketing and sexual health risk in their communities. It was also the first to use innovative methods such as GIS and photovoice to provide visual evidence of the high density of alcohol outlets and advertising linked to youth drinking patterns and sexual health risk. The use of photovoice also allowed youth to creatively use photography to tell their story and question the status quo.

This study of alcohol availability, alcohol marketing, drinking patterns and sexual health risk amongst South African youth has highlighted how the environments that both rural and urban youth live in are characterized by easy and widespread alcohol availability, and a bombardment of alcohol-promoting messages through marketing and advertising. By young people’s own estimation, these factors in turn influence drinking patterns, resulting in substantial risk for youth, particularly sexual risk and violence for young women. Our results underline the importance of developing and implementing strategies at policy and community levels that tackle the broader context and structural factors to protect youth. The influence of alcohol availability and advertising on youth drinking patterns needs to be countered by a strengthened legislative framework complemented by strong implementation of both existing regulations and evidence-based interventions at community level. Alcohol as a structural driver of HIV and sexual health risk requires strong structural solutions that address policies and implementation from national to community levels. It is imperative that the proposed South African alcohol legislature that seeks to safeguard young people from high exposure to alcohol availability and marketing, be passed into law in order to protect them from harmful use of alcohol and associated sexual risk including HIV and sexual violence.