Adolescent alcohol consumption: protocol for a scoping review of screening and assessment tools used in Africa

With 3 million deaths per year attributable to its use, alcohol is a major public health problem world-wide [1‐4]. This is particularly true in sub-Saharan Africa which has the highest burden of disease and injury attributed to alcohol of any region [1, 5]. Alcohol related harms include sexual risk taking [6], adverse HIV outcomes, self-harm, suicide, and the perpetration of sexual violence [7].

Adolescent drinking in particular is a major global health concern [8]. Harmful alcohol use in adolescence causes alterations in attention, verbal learning, visuospatial processing and memory, as well as altered development of grey and white matter of the central nervous system [9]. Alongside the neurocognitive impacts of adolescent alcohol use, there is also evidence that alcohol use affects social and emotional development, including family, peer and sexual relationships, as well as causing emotional changes and mental health problems [10, 11].

Risk of harm increases with volume and frequency of alcohol use. It is therefore necessary to quantify patterns of alcohol use among drinkers if risk of harm is to be assessed. Heavy episodic drinking (HED) is defined as “drinking at least 60 g or more of pure alcohol on at least one occasion in the past 30 days” and is one of the most significant indicators for alcohol related harm [12]. Over half of adolescents who drink in Africa engage in HED [1]. It is also known that the alcohol industry has been expanding its commercial activities in Africa [13, 14] using strategies that target young people and women [7].

To implement, monitor and measure the impact of interventions to tackle alcohol misuse, there must be effective screening and assessment tools. However, measuring alcohol use is challenging in sub-Saharan Africa, especially in contexts where traditional homemade brew represents the majority of alcohol use [15]. Measures for the use of homemade brew are hard to standardise. For example, locals may refer to the amount of brew consumed by the amount of money spent [15], rather than the volume of alcohol contained in the beverage. Standardised locally appropriate monitoring tools are therefore needed.

There are a number of screening and assessment tools in use across the world, which rely on self-reported use. Most common are the CAGE questionnaire [16], AUDIT (Alcohol Use Disorders Identification Test) [17] and its modifications and CRAFFT [18], which is specific to adolescents. There is a large body of literature assessing the effectiveness of such tools across a range of settings. Generally, AUDIT is considered to be a strong screening tool for assessing alcohol use in young people [19] and this has been seen in Africa [20]. CRAFFT has also been shown to have adequate psychometric properties for detecting alcohol use disorders in adolescents [21] and found to have adequate internal consistency and acceptable reliability within a population of South African adolescents [22]. Alcohol biomarkers offer an objective measurement of a person’s alcohol consumption but have limitations in that they are best in determining if a patient is abstinent from alcohol or a very heavy consumer [23], they are expensive to use [24] and are particularly inaccessible in sub-Saharan Africa due to weak labatory infrastructure [25].

While there has been some work toward comparing and validating tools, there has been no synthesis of the available evidence for this population in this setting. This needs to be done because alcohol use disorders are a significant cause of mortality and morbidity; treatments are available and outcomes can be improved by early detection and intervention [26]. Standardised, culturally appropriate tools for the implementation and monitoring of these detection and intervention strategies are therefore needed. In order to address this gap, the current scoping review will examine and map the range of tools in use and create an evidence base for future research in this area.

A scoping review was considered to be the appropriate methodology to assess alcohol measurement tools. Scoping reviews are unique in their ability to provide a broad overview of a research area, where very specific research questions have not been identified. It is more useful to summarise and disseminate known evidence, identifying gaps in the existing literature, which may lead to identification of research questions for systematic review [27, 28]. Scoping review methodology is also favourable as a range of sources of information, including grey literature, can be included for review. This protocol development has drawn on elements of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [29], which will also be used in reporting our findings. For this protocol, we have followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement as appropriate for this review, which can be found in Additional file 1 (Table 1).

This scoping review will draw on the stepwise methodological framework described by Arksey and O’Malley [27], with updates by the Joanna Briggs Institute (JBI) [28] and by Levac et al. [30].

A key strength of the study described within this protocol is the use of a scoping review methodology, which will enable us to follow a transparent and reproducible procedure while being flexible to amendments as we become more familiar with the data. In this protocol, we have described the need for this review, who it will benefit, our target population, setting, search strategy and data we anticipate extracting. Publication of this research protocol is in keeping with good, transparent research practise, as it reduces the risk of bias and selective reporting while providing an opportunity to strengthen our proposed review.

As there are no human participants involved, there will be no requirement for ethical approval. Patients and/or the public were not involved in the design of this protocol; however, the authors will work with patients and members of the public through stakeholder and other PPI research forums in disseminating the findings of the review both in the UK and the Global South.

Findings will be disseminated widely through peer-reviewed publication and in various media, for example, conferences, congresses or symposia. This scoping review will inform other researchers in the field of adolescent health as a standalone piece of work but will also provide a baseline resource which can be used to inform future research planning. To the best of our knowledge, this scoping review is the first attempt to systematically identify and map the alcohol screening and assessments tools used to target adolescent alcohol use in Africa.