Correlates of alcohol consumption in rural western Kenya: A cross-sectional study

The third goal of the 17 Sustainable Development Goals (SDGs) focuses on health including mental health and specifies the strengthening, prevention and treatment of the harmful use of alcohol [1]. Harmful alcohol consumption is a major public health problem and a risk factor for poor health globally. Alcohol consumption is the world’s third largest risk factor for disease and disability; in middle-income countries, it is the greatest risk factor for disease, a causal factor in 60 types of diseases and injuries, and a component cause in 200 others [2, 3]. Alcohol abuse is related to the psychological, physical and social health of communities, families and individuals in developed and developing countries [4].

Alcohol-related problems are emerging as major health issues in Africa [5]. Despite this, only a few surveys on alcohol consumption have been conducted in sub-Saharan Africa, especially in rural settings [3, 6, 7] where the economic status, lifestyle, and culture differs from that in urban areas. Most of the available data are disaggregated at the regional level and hence are of little use at the sub-regional/county level: the basic operational level of the health system in Kenya.

In Kenya, reliable data on alcohol consumption and its effects in rural communities are limited, yet consumption of traditional brews is a common practice in many rural parts of the country [5]. Effects of alcohol consumption are emerging in Kenya. A study conducted in Eldoret found that 23.4% of crash-involved patients of motor vehicle accidents were blood alcohol concentration positive and 12.2% were intoxicated [8]. A survey among women in Nairobi found that women who had partners who drink alcohol were significantly more likely to experience both lifetime violence and violence in the preceding year, and those whose partners were intolerable drinkers had a significantly higher reporting of domestic violence compared with those whose husbands drank moderately [9]. Media reports of deaths from consumption of homemade alcohol in Kenya are common [10, 11]. Despite these problems, there is scarce information on the main determinants of alcohol consumption in rural Kenya. Therefore, it is important to understand the prevalence and the main determinants of alcohol drinking to inform the planning of public health intervention strategies to mitigate the problem. This paper presents data on the prevalence and determinants of alcohol consumption in a rural sub-county in western Kenya. The study was conducted as a preliminary stage of an intervention project to reduce hazardous alcohol consumption in the sub-county.

This study provides a snapshot of the prevalence and correlates of alcohol consumption in Kakamega County for the first time. The sex standardised prevalence of current alcohol intake was 31.7%, which is much higher than the official 2012 national level of 13.3% [26] and the prevalence of 9.2% reported in the neighbouring Kisumu County [1]. Factors that could explain these discrepancies include potential underreporting in previous surveys conducted by government agencies (consumption of some traditional brews used to be illegal for a long time [27]) and the true regional variations in the prevalence of alcohol consumption in Kenya. The reported prevalence is, however, similar to that in the neighbouring country of Uganda (28.6%) [7]; the second highest alcohol consumer in Africa [25]. This is not surprising given that Western Kenya borders Eastern Uganda and the residents in the bordering areas have similar ethnic and cultural backgrounds including consumption of traditional alcohol.

The most common types of alcohol consumed in the study area were homemade traditional brews namely, chang’aa and busaa, which explains why the usual drinking place was the seller’s home. Chang’aa is a high alcohol content spirit-like clear drink made by fermenting a mixture of corn/sorghum/millet and sugar for about a week followed by distillation whereas busaa is a malt liquor made from fermenting corn flour and sorghum/millet over a shorter period of time (typically two days) [28]. These traditional brews are not standardised, but some studies have estimated their alcohol content to range from 15.3%–34% for chang’aa and 3.9%–5.4% for busaa [28, 29]. For many years, the Chang’aa Prohibition Act of 1980 [27] prohibited the production, supply, possession, and consumption of chang’aa, but not of busaa, in Kenya. The Alcoholic Drinks Control Act of 2010 [30] and the Alcoholic Drinks Control Amendment Bill of 2013 [31] repealed the Chang’aa Prohibition Act and focused on production, sale, and licensing rather than on illegalising traditional brews. Thus, traditional brews are legal if the producer is licensed. However, it is difficult for traditional brewers to meet the high standards for licensing as stipulated in the law. The traditional brews are usually not sold in bars or in shops but in people’s homes. One village could contain 3 to 5 such drinking places and this, coupled with affordable prices, ensures that the brews are easily accessible. These results differ from those of another study conducted in a rural setting in eastern Kenya which reported that the most commonly consumed alcohol type was bottled beer (64.8%) followed by local brews [3]. However, this study by Kinoti and colleagues was based on a smaller (N = 217) non-random sample, and hence it is subject to a greater degree of random error and selection bias. The price of a half-litre bottle of beer starts from 1.3 US$ (130 Ksh) which is quite expensive for most villagers, but the price of a cup of local brew is only about 0.5 US$; which highlights the issue of affordability of local brews.

The finding of a gender gap in alcohol consumption is similar to what other studies from East Africa have reported [1, 7]. The reasons for the prevalence gap between men and women might be cultural, for instance, gender-based distinctions between male and female based on the traditional system of patriarchy in the community. A qualitative study in the neighbouring Uganda found that alcohol intake among men is associated with masculinity, social dependence and lesser financial empowerment among women [32]. Men have easier access to money than women do. Among rural women, alcohol intake is associated with defiance of the feminine ideals of domesticity [6]. A qualitative study might help to elicit other factors for the gender discrepancy in alcohol intake in the current setting.

Although based on small numbers, we noted some differences in the drinking behaviours between men and women. The proportion of individuals who drank at home was higher among women than among male drinkers. This may be because women in this setting are more likely to be uncomfortable to drink in public places because drinking among women is perceived to be socially undesirable. The most popular drink among women was busaa while among men it was chang’aa. Women prefer busaa over chang’aa because of the former’s lower alcohol content [28] and sweeter flavour.

The findings of this study show that having family members and friends who drink is strongly associated with current alcohol drinking status and hazardous/high-risk alcohol drinking. Possible explanation for this can be the influence of peer pressure and easier access to alcohol because friends/family members may buy alcohol for each other. The business of brewing and selling local brews is common in the study setting because of the prevailing poverty situation and the lack of employment opportunities to meet the costs of living including school fees for children. Although these businesses are illegal, they continue to flourish due to limited alternative economic opportunities and probably weaknesses in law enforcement [33].

This study has some limitations. First, some participants, especially women, might have underreported their alcohol consumption due to social desirability and stigma associated with alcohol consumption. Alcohol use by women is a taboo in the study community and women who drink alcohol are held in low esteem. Moreover, as mentioned above, consumption of chang’aa was for a long time illegal, which may further affect reporting by both genders. To minimise this bias, data collectors were trained to reassure respondents and to ensure confidentiality before asking questions. Second, the sample size was insufficient to allow precise assessment of multiple correlates of alcohol intake. This may explain why some of the estimates have wider confidence intervals. Third, the measurement of alcohol units in this setting was a challenge because it is difficult to standardise the alcohol content of homemade brews and to estimate the amount consumed. We used the data from a study conducted in 2010 that estimated the alcohol content of traditional brews in western Kenya to be 34% for chang’aa and 4% for busaa [28]. We also asked participants to estimate their alcohol intake based on measurement containers commonly used by alcohol sellers. Finally, the number of adverse life events, social support, and severity of psychological distress may be associated with hazardous alcohol use, but the present study did not collect data on these variables. Nonetheless, a previous study in Kenya did not find any significant association between these variables and current alcohol intake [6]. Finally, given that this study was conducted in only one sub-county, generalisability of the findings may be limited to other regions with similar socio-cultural and economic profile as the study sub-county.

In this study conducted in rural western Kenya, we found a prevalence of alcohol intake that is higher than the regional and national levels. Drinkers mainly consumed homemade brews that are cheaper, culturally appropriate and easily accessible. The results on the determinants of alcohol intake suggest that the social environment, rather than an individual’s socio-demographic characteristics, is the main determinant of alcohol consumption in this setting. Although this observation could be due to reverse causation, the findings imply that interventions to mitigate alcohol consumption in this area will have to target the social networks of the alcohol consumers, change the drinkers’ attitude towards alcohol, and tackle the issue of availability of unlicensed traditional brews. Given the resource constraints to tackle the problem of alcoholism in the study area, innovative community-based approaches using locally available resources to mitigate the problem of alcoholism should be piloted and implemented in this and similar contexts. Moreover, the poor economic status in the study area should be addressed and alternative sources of income for traditional alcohol brewers and sellers should be created.