Alcohol and substance use prevention in Africa: systematic scoping review

ABSTRACT

Background

Alcohol and substance use has been a long-standing public health challenge across the globe, including in Africa. Research evidence attests that there is no singular approach to the prevention of this problem. This study used a scoping review to systematically appraise existing research evidence on the prevention of alcohol and substance use in Africa.

Methodology

A systematic search for literature on alcohol and substance use prevention between 2008 and 2018 in African countries was done in PubMed, EBSCOhost, and Web of Science databases. The study employed Arksey and O’Malley scoping review framework. Search terms included those relevant to the prevention of alcohol and substance use. Abstracted data were synthesized, thematically analyzed, and presented in a narrative format.

Results

A total of 34 peer-reviewed studies were selected for the final review in the current study. Alcohol is the predominantly used substance in Africa, among many other substances. A wide spectrum of factor risk and protective factors were reported. Prevention interventions were categorized as individual, family, school, workplace, environmental, media, as well as community-based prevention interventions.

Conclusions

While a variety of targeted prevention interventions have been implemented in the African continent, their effectiveness remains to be further elucidated, explored, and tested.

KEYWORDS:

• Alcohol and substance use
• prevention
• systematic scoping review

Introduction

Alcohol and substance use has been a long-standing public health challenge across the globe, including in Africa (Mbwambo et al., 2012). The detrimental use of alcohol and other substances has been reported to cause devastating consequences on individuals, families, and societies (Medina-Mora, 2005). These include diseases, a psychological, social, and economic burden in societies, and many other physical harms like road traffic accidents (Hall et al., 2016). In 2008, the World Health Organization estimated that alcohol, tobacco, and drug use contributed to 12.4% of deaths globally in 2000 (WHO, 2018). Furthermore, 2002–2030 projections by the Global Burden of Disease Project estimate that five of the six fastest-growing causes of global mortality are related to substance use (WHO, 2018). In light of this, the protection of the health of populations by preventing the harmful use of alcohol and other substances, and its effects remains a public health priority (Degenhardt et al., 2016a; Newton et al., 2017; WHO, 2013). WHO has consequently urged member states to interrupt the growing destructive trend, and reduce its related ills through prioritizing alcohol and substance use prevention measures and programs (Renstrom et al., 2017).

This call by WHO necessitates that effective substance use prevention research be conducted (Newton et al., 2017). As global epidemiological transitions from diseases of poverty to non-communicable diseases progress, substantial swing in the burden of disease and health risks among adolescents and young adults are expected to mirror the significant role played by substance use (Degenhardt et al., 2016a). To interrupt this trend, and reduce the associated harms, effective substance use prevention research is paramount (Newton et al., 2017). Currently, there is a paucity of information in epidemiological data about the extent of drug use prevention worldwide and particularly in Africa, which has been reputed to hinder effective global policy responses (Degenhardt et al., 2016a; WHO, 2018). To date, limited studies have been published on alcohol and substance use prevention. Furthermore, alcohol and substance use prevention research has not yet been extensively reviewed in Africa. Therefore, available information and existing research gaps in the selected studies are discussed and summarized in this review. The aim of the current scoping review was to systematically appraise existing research evidence on the prevention of drug and substance use in Africa. The specific objectives were to:

• Identify drugs and substances used across Africa

• Identify risk and protective factors that contribute to alcohol and substance use as a public health problem in Africa

• Classify prevention strategies used in preventing alcohol and substance use in Africa

Materials and methods

Study design

We conducted a scoping review to appraise the evidence that exists on drug and substance abuse in Africa. Scoping review is defined as “a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting, and synthesizing existing knowledge” (Colquhoun et al., 2014). Arksey and O’Malley’s scoping review framework guided the review (Arksey & O’Malley, 2005), and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used (Moher et al., 2015). This methodology was chosen for its aptness in achieving the objectives of the study, not only in mapping the evidence on what is known about the prevention of drug and substance abuse in Africa but also synthesizing available evidence.

Search strategy

Selection and categorization of articles admitted into the study were based on the following criteria:

• Studies that focused specifically on the prevention of drug and substance use in Africa.

• Studies that are published between 2008 and 2018.

• The studies had to be in English.

With clarified criteria that would guide admission of the desired studies, we then searched databases for works that evidenced drug and substance use in Africa. Databases searched included Ebscohost (MEDLINE, PsycINFO PsycARTICLES, and Academic Search Complete CINAHL with Full Text), PubMed, and Web of Science. The search terms used are shown in Table 1.

Table 1. Search strategy key terms.

Keywords	Synonyms
Drug and substance abuse	Substance-related disorder, substance abuse, substance use disorder*, substance use, substance dependence, substance addiction Drug abuse, drug use disorder, drug use, drug dependence, drug addiction
Prevention	Prevention, control, intervention, inhibition, interception, circumvention
Africa	Africa, South of the Sahara, Sub-Saharan Africa, Central Africa, Eastern Africa, Southern Africa, Western Africa, SADC countries, SACU countries, North Africa, Central Africa, Southern Africa, ECOWAS	Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Democratic Republic of the Congo, Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Mauritania, Mauritius, Morocco, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Eswatini, Tanzania, Togo, Tunisia, Uganda, Zambia, Zimbabwe
Filters: 2008– 2018, English language, Human research

Screening of candidate papers at the title stage that was done by all reviewers (LMM, RT, MSM, JTK, LG, ET & PM). The papers were then imported into Mendeley reference management software, and at this juncture, duplicates were removed. A sample of 15 academic citations was employed to pilot the abstract screening tool to observe the reviewer interrater agreement. A kappa interrater agreement calculation was used to indicate the agreement rate. After determining the agreement levels, all reviewers screened the abstracts eligibility based on criteria earlier agreed on.

Appraising the quality of evidence

According to the Cochrane Collaboration, at some stage in the process of evidence synthesis, a quality filter needs to be applied, and flawed studies rejected (Higgins et al., 2011). Although the Arksey and O’Malley, (2005) systematic review framework followed in this study supports this principle, the purpose of study appraisal is not to reject studies, but to give a more vibrant picture of the extent and range of included studies. This is because this scoping review sought to explore the highly diverse subject matter of prevention of drug and substance use. Therefore, the quality of the studies was determined through study appraisal using the mixed-method appraisal tool (MMAT) – Version 2018 (Nha Hong et al., 2018). An overall quality percentage score for the included studies was calculated, and scores interpreted as low quality (≤50%), average quality (51–75%), and high-quality (76–100%).

Extracting and reporting the data

Comprehensive and uniform data mining forms were employed for the sieving and categorization of included study components of interest. Admitted literature was scrutinized for their focus on the prevention of drug and substance use in Africa. These were appropriately noted and revised and categorized across all studies.

This study applied the adapted version of PRISMA (Moher et al., 2015) for results reporting. The use of a modified version as the best strategy for reporting results from scoping review is a recommendation by Halas et al., (2015). The review, therefore, used the PRISMA checklist that was adapted to include only the constituents that resonate with the underpinnings of scoping review methodology while eliminating features that are not, like the ones that relate to bias.

Screening results

As shown in Figure 1, a total of 32,643 articles were identified from searched databases. An additional two were mined from gray literature repositories identified through snowballing. We screened 38 articles having excluded a total of 32,605 up to full article screening stage for the reasons shown in the PRISMA diagram below (Figure 1). Thirty-four articles were ultimately admitted for thematic analysis in this study.

Figure 1. PRISMA Diagram.

Results

We present our findings on the prevention of drug and substance use in Africa. A total of 34 peer-reviewed studies were included in the final review following a literature search on 3 different search engines (PubMed, Web of Science, and Scopus) using carefully selected keywords and appropriate Boolean operators. Of the thirty-four articles reviewed papers, eleven were from Southern Africa six were from North Africa, two from West Africa, nine from East Africa. Six papers were from several African countries, while there were no articles from Central Africa. The results are organized into four main sections: major characteristics of the study population, types of substances used, risk and protective factors, and prevention interventions in the studies.

Characteristics of the study population

Appendix A shows the major characteristics of the study population by gender, age, level of education, and the types of substances used. With regard to gender, the findings from the studies show that the study population comprised both males and females (Agaku et al., 2015; Birhanu et al., 2014; Cubbins et al., 2012; Duresso et al., 2018; Embleton et al., 2013; Glozah et al., 2015; Koopman et al., 2008; Meade et al., 2015; Medley et al., 2014; Onya et al., 2012; Papas et al., 2012; Peltzer & Pengpid, 2012; Scheibe et al., 2016; Sreeramareddy et al., 2014; Stengel et al., 2018; Takahashi et al., 2018), with only a few focusing on either males (Ghaddar & Ghaly, 2016; Sfendla et al., 2018) or females (Ghebremichael et al., 2009; Watt et al., 2016; Wechsberg et al., 2008). There is an age variation among the study populations across all the studies with an age range of 10–65 years. There is also diversity in the type of participants who comprised the study population. Some studies focused on self-injecting drug users (Ghaddar & Ghaly, 2016; Stengel et al., 2018), adolescents (Agaku et al., 2015; Birhanu et al., 2014; Mushanyu et al., 2017; Onya et al., 2012), vulnerable children (Beard et al., 2010; Embleton et al., 2013), adults with substance use disorders (Crunelle et al., 2018) undergraduate and postgraduate students (Duresso et al., 2018; Glozah et al., 2015) outpatients (Sfendla et al., 2018) and HIV positive patients (Medley et al., 2014; Papas et al., 2012). Moreover, results show that most of the study population have at least attended secondary school (Birhanu et al., 2014; Medley et al., 2014; Onya et al., 2012; Peltzer & Pengpid, 2012; Sfendla et al., 2018; Takahashi et al., 2018). Diverse presentations were also observed with regard to study settings. For instance, out of the 12 studies in the Southern region, 10 were from South Africa (Cubbins et al., 2012; Koopman et al., 2008; Meade et al., 2015; Medley et al., 2014; Mushanyu et al., 2017; Onya et al., 2012; Peltzer & Pengpid, 2012; Scheibe et al., 2016; Schneider et al., 2016; Watt et al., 2016; Wechsberg et al., 2008), and the study settings were urban (Koopman et al., 2008; Peltzer & Pengpid, 2012; Scheibe et al., 2016; Wechsberg et al., 2008), rural (Cubbins et al., 2012), and peri-urban areas (Meade et al., 2015; Onya et al., 2012; Watt et al., 2016).

Types of substances used

The results indicate alcohol (Birhanu et al., 2014; Cubbins et al., 2012; Embleton et al., 2013; Ferreira-Borges et al., 2015; Ghebremichael et al., 2009; Glozah et al., 2015; Kalema et al., 2015; Koopman et al., 2008; Medley et al., 2014; Onya et al., 2012; Papas et al., 2012; Peltzer & Pengpid, 2012; Schneider et al., 2016; Takahashi et al., 2018, 2017; Watt et al., 2016; Wechsberg et al., 2008) as the most predominantly used substance in most of the countries. The second commonly reported type of substance used in other countries is cigarette smoking (Ali et al., 2012; Birhanu et al., 2014; Embleton et al., 2013; Gravely et al., 2018; Jradi et al., 2013; Peltzer & Pengpid, 2012; Sreeramareddy et al., 2014; Takahashi et al., 2017). Additionally, studies from South Africa indicate a variety of substances used such as alcohol (Cubbins et al., 2012; Koopman et al., 2008; Medley et al., 2014; Onya et al., 2012; Peltzer & Pengpid, 2012; Schneider et al., 2016; Watt et al., 2016; Wechsberg et al., 2008), methamphetamine (Meade et al., 2015; Mushanyu et al., 2017; Wechsberg et al., 2008), amphetamine-type stimulants (ATS) (Scheibe et al., 2016), heroin (Scheibe et al., 2016; Wechsberg et al., 2008), cocaine (Wechsberg et al., 2008), crack cocaine (Wechsberg et al., 2008), tobacco (Wechsberg et al., 2008), cannabis (Wechsberg et al., 2008), methaqualone (Wechsberg et al., 2008), ecstasy (Wechsberg et al., 2008), marijuana (Wechsberg et al., 2008), cigarette smoking (Peltzer & Pengpid, 2012), snuff (Peltzer & Pengpid, 2012), chewing tobacco (Peltzer & Pengpid, 2012), cigars (Peltzer & Pengpid, 2012).

Risk and protective factors identified in the studies

Appendix B gives an overview of risk and protective factors for substance use and prevention interventions for substance use in Africa. A wide spectrum of risk factors were reported in the accepted studies, ranging from age (Crunelle et al., 2018; Cubbins et al., 2012; Sreeramareddy et al., 2014), gender (Birhanu et al., 2014; Cubbins et al., 2012; Medley et al., 2014; Scheibe et al., 2016; Sreeramareddy et al., 2014; Takahashi et al., 2017), level of education (Crunelle et al., 2018), marital status (Cubbins et al., 2012; Sreeramareddy et al., 2014), unemployment (Ratliff et al., 2016; Sreeramareddy et al., 2014), area of residence (Sreeramareddy et al., 2014), occupation (Sreeramareddy et al., 2014), employment status (Cubbins et al., 2012; Sreeramareddy et al., 2014), lack of alcohol use screening (Koopman et al., 2008), poor mental health (Peltzer & Pengpid, 2012; Sfendla et al., 2018), psychological factors (anxiety/stress/depression) (Peltzer & Pengpid, 2012; Sfendla et al., 2018), accessibility of alcohol and substances (Duresso et al., 2018; Embleton et al., 2013; Kalema et al., 2015; Meade et al., 2015; Onya et al., 2012; Scheibe et al., 2016; Takahashi et al., 2017), availability of alcohol and substances (Duresso et al., 2018; Meade et al., 2015; Onya et al., 2012; Takahashi et al., 2017), participants’ place of origin (Birhanu et al., 2014; Cubbins et al., 2012; Meade et al., 2015; Onya et al., 2012), adults drug users (Onya et al., 2012), adult drug dealers (Onya et al., 2012), antisocial behavior among adults in the community (Onya et al., 2012), incomplete adherence to medication (Medley et al., 2014), high risk sexual behaviors (Medley et al., 2014), ethnicity (Cubbins et al., 2012; Wechsberg et al., 2008), race (Scheibe et al., 2016), socioeconomic background (Embleton et al., 2013; Meade et al., 2015), social background (Embleton et al., 2013; Meade et al., 2015), scarcity of counseling skills (Schneider et al., 2016), lack of clarity for PHCW regarding guidelines on alcohol use when on ART (Schneider et al., 2016), attitudes and perceptions (Watt et al., 2016), misinformation (Watt et al., 2016), lack of religious affiliation (Cubbins et al., 2012; Sreeramareddy et al., 2014), low self-esteem (Glozah et al., 2015), to poverty (Glozah et al., 2015). Only one study in Southern Africa did not state the risk factors observed (Mushanyu et al., 2017). Overall, age and gender were the most reported risk factors in the studies.

Additional risk factors reported in East Africa, North Africa as well as in Central Africa were lack of implementation and enforcement of policies (Ali et al., 2012; Ferreira-Borges et al., 2017; Ratliff et al., 2016), lack of refusal skills (Kalema et al., 2015), social pressure (Birhanu et al., 2014; Duresso et al., 2018; Embleton et al., 2013; Takahashi et al., 2017), poor academic performance (Birhanu et al., 2014), addiction (Beard et al., 2010; Embleton et al., 2013), early aggressive behavior (Ghebremichael et al., 2009), sexual abuse (Ghebremichael et al., 2009) as well as women who reported difficulty in conceiving (Ghebremichael et al., 2009). Of particular note is media and advertising (Ferreira-Borges et al., 2017) being reported as a risk factor in Central Africa and lack of inclusion of substance use in the school curricula (Agaku et al., 2015).

Prevention interventions identified in the studies

A wide range of prevention interventions for substance use was identified throughout the African continent as shown in Appendix B. Both individual and community-based prevention interventions have been reported. Of note is that some prevention intervention strategies were demographic groups specific, while others were nonspecific, targeting the general population. The demographic group’s specific prevention interventions employed in Southern Africa targeted groups such as people living with HIV (Medley et al., 2014), general practitioners (Koopman et al., 2008), high school students (Onya et al., 2012), Community Popular Opinion Leaders (CPOL) (Cubbins et al., 2012) as well as Cape Town Women’s Health CoOp (Wechsberg et al., 2008). In North Africa, the reported demographic-specific target groups included Male Injecting Drug Users (Ghaddar & Ghaly, 2016).

In Southern Africa, prevention interventions reported varied from use of Primary Health Care Settings (Koopman et al., 2008), more explicitly targeting general practitioners (Koopman et al., 2008), use of Community Popular Opinion Leaders (CPOL) community-based intervention (Cubbins et al., 2012), individual-level counseling strategies (Wechsberg et al., 2008), training and empowerment of PHCW (Schneider et al., 2016), an improvement on levels of information disseminated to target groups and addressing misinformation (Schneider et al., 2016; Watt et al., 2016) as well as generation of public and health policymakers awareness on the detrimental effects of substance abuse using various media platforms such as social media and text messages to target groups (Watt et al., 2016). Additionally, enforcement of Fiscal (Price and Tax) Policy (Sreeramareddy et al., 2014), Trade Policies on tobacco products (Sreeramareddy et al., 2014) as well as prevention interventions targeting to influence the attitudes and perceptions (Watt et al., 2016) of target groups and the community at large were also reported in the selected studies as shown in Appendix B.

In East Africa, reported prevention interventions included government sets guidelines for screening and management of chronic alcohol poisoning in health centers (Kalema et al., 2015), stricter control over the production and sale of alcohol as well as Fiscal (Price and Tax) Policy (Kalema et al., 2015), licensing, pricing and taxation (Kalema et al., 2015), age restrictions (Kalema et al., 2015), restrictions on sales hours and days (Kalema et al., 2015), and promotion and advertisement bans as well as a comprehensive alcohol policy (Kalema et al., 2015), misuse prevention using information and sensitization campaigns (Kalema et al., 2015), brief interventions for hazardous drinkers (Kalema et al., 2015), support and treatment for addicted persons (Kalema et al., 2015) and enforcement of regulatory measures (Kalema et al., 2015), changes in the environment to restrict access to alcohol (Takahashi et al., 2018) as well as the use of CHWs in impoverished settings (Takahashi et al., 2018) (Appendix B).

Medical school-based preventive interventions were reported in North Africa, more specifically medical schools of the Middle Eastern and North African (MENA) regions (Jradi et al., 2013). Use of physicians and other healthcare professionals in the WHO MPOWER package and interventions (Jradi et al., 2013), provision of psycho-educational programs for individuals with drug dependence and helping them to find social support, job opportunities, improve their level of education as well as provide adequate medical care while also taking care of their depressive symptoms among other interventions (Sfendla et al., 2018) as shown in Appendix B.

In West Africa, reported prevention interventions included life skills training as well as the use of Alcohol Abstinence Self Efficacy Scale (Glozah et al., 2015), use of peer education facilitators/educators especially those that were using drugs (Stengel et al., 2018). No prevention intervention strategies were reported in Central Africa.

Discussion

The scoping review showed that a variety of substances are used across the African continent including but not limited to alcohol, tobacco, methamphetamine, glue, cigarettes, miraa, marijuana, petrol as well as other injecting drugs. Findings from the studies conducted in the Southern African region, particularly from South Africa, have shown that Methamphetamine and its related products are predominantly used (Meade et al., 2015; Mushanyu et al., 2017; Scheibe et al., 2016). This finding is also supported by the United Nations World Drug Report of 2011 (UNODC, 2011), which indicated that the use of Amphetamine-Type Stimulants (ATS) products including methamphetamine had been largely alluded to in the Southern region of Africa in countries like Zambia, Zimbabwe with South Africa being more dominant. Additionally, the (UNODC, 2011) report indicated that the African region takes the lead in distributing ATS and methamphetamine with West Africa as the major supplier of the products to the East Asian region. The marketplace for these illicit drugs has stretched from the Asian region to Europe, and it has been noted that there people who transport the drugs to the region (Ibid).

Some of the studies focused on adolescents (Agaku et al., 2015; Birhanu et al., 2014; Mushanyu et al., 2017; Onya et al., 2012) and vulnerable children (Beard et al., 2010; Embleton et al., 2013) who used or had access to drugs. This finding resonates with Degenhardt et al. (Degenhardt et al., 2008), who reported that trends have shown that drug initiation mostly starts between the onset of puberty until late adolescence in most countries. Furthermore, the authors also argued that the longevity of the use of illicit drugs prolongs into adulthood and supersedes the use of licit drugs (Degenhardt et al., 2008).

Our scoping review has shown that age, area of residence, accessibility of alcohol and substances, availability of alcohol and substances, participants’ place of origin, antisocial behavior among adults in the community, ethnicity, social background, low self-esteem, and poverty are risk factors for substance use. These findings are in agreement with (Haase & Pratschke, 2010), who have previously reported that age of a young person, ethnicity, self-esteem or self-concept, use of other substances as a risk for using more substances and peer pressure or having a girlfriend or boyfriend using substances are risk factors for substance use (Haase & Pratschke, 2010). Risk factors related to a young person’s parents and home, such as lack of parental involvement and concern, use of substances by significant family members as well as risk factors related to the school environment have also been reported (Haase & Pratschke, 2010). The risk factors findings of our scoping review, therefore, correlate well with other reports and publications (Deb & Gupta, 2017; Morojele et al., 2013; National Institute on Drug Abuse, 2003; Spooner & Hetherington, 2004; Wallace et al., 2003) Our findings also show gender to be a risk factor for substance use. However, Hasse & Pratschke (Haase & Pratschke, 2010), deviates from that notion, reporting that gender is not necessarily a risk factor for substance use in a different study.

Vulnerable populations for substance use were also identified in our scoping reviews, such as people living with HIV, high school students, Male Injecting Drug Users, and Street children. In agreement with our findings, other studies have previously reported the existence of vulnerable populations for substance use (Agerwala & McCance-Katz, 2012; Naidoo et al., 2016).

A wide spectrum of prevention interventions is reported in our scoping review. The reported prevention interventions fall into various broad categories, such as individual-based interventions, family-based interventions, school-based interventions, workplace-based interventions, environmental-based interventions, media-based interventions, as well as community-based prevention interventions. Prevention interventions shown in this scoping review include use of Primary Health Care Settings, more specifically targeting general practitioners, life skills training, use of Alcohol Abstinence Self Efficacy Scale, use of Community Popular Opinion Leaders (CPOL) community-based intervention, individual-level counseling strategies, training and empowerment of PHCW, an improvement on levels of information disseminated to target groups and addressing misinformation, generation of public and health policymakers awareness on the detrimental effects of substance abuse using various media platforms such as social media and text messages to target groups.

Additionally, enforcement of Fiscal (Price and Tax) Policy, Trade Policies on tobacco products as well as prevention interventions targeting to influence the attitudes and perceptions of target groups and the community at large. The findings of our scoping review correlate well with other reports and publications focusing on various prevention interventions (Deb & Gupta, 2017; Kumpfer, 2014; Riva et al., 2018; Warren, 2016; WHO, 2018).

Conclusion

Our scoping review has shown that a variety of substances are used in Africa, with the Southern African region having the most significant variance. Of this great variance, the majority are illicit. Furthermore, alcohol and substance use is more prevalent in urban areas as opposed to rural areas. Different populations have been reported to use alcohol and substances in the African continent, among them adolescents as young as 10 years old, which is worrying. Lastly, most studies in the scoping review comprised both males and females, which indicates that both genders use alcohol and substances alike. The findings also indicated the existence of a wide range of risk factors for substance use throughout the African continent.

Additionally, there exists a diversity of substance use vulnerable population groups requiring demographic-specific prevention interventions to ensure their effectiveness. Currently, a wide spectrum of substance use prevention interventions has been implemented through ought the African continent, ranging from individual-based interventions, family-based interventions, school-based interventions, workplace-based interventions, environmental-based interventions, and media-based interventions to community-based prevention interventions. The effectiveness of these various prevention interventions in the African continent remains to be further elucidated, explored, and tested.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendix A.

Summary of study population major characteristics and types of substances used

Reference	Region of study	Country of Study	Study Setting	What are the characteristics of the study population?	Types of substances used in this study
(Agaku et al., 2015)	Africa	30 African Countries	Secondary schools	Males and females; Adolescents aged 13– 15	Tobacco
(Beard et al., 2010)	Africa	Low- and middle-income countries	Not stated	Children of sex workers who sometimes run the risk of entering the profession or being trafficked	Not stated
(Crunelle et al., 2018)	Africa	Not stated	Not stated	Adult patients with Substance Use Disorders and Attention Deficit Hyperactivity Disorder	Not stated
(Ferreira-Borges et al., 2015)	Africa	Reviewed national Alcohol policies of 46 African countries	Not stated	Alcohol Policy documents	Alcohol
(Kalema et al., 2015)	East Africa	Uganda	Not stated	Policy documents	Alcohol
(Takahashi et al., 2018)	East Africa	Kenya	Rural setting	Adult household members aged 18– 65; The exclusion criteria was: 1. Being pregnant 2. Having a history of treatment for alcohol-related problems or a psychiatric illness 3. Involvement in another alcohol-related intervention	Alcohol
(Takahashi et al., 2017)	East Africa	Kenya	Rural setting	Males and females’ Men and women aged 18–65 years; Residing in Ikolomani Subcounty.	1. Alcohol 2. Cigarette Smoking
(Gravely et al., 2018)	East Africa	Uganda	Urban setting	1. Hospitality sites 2. Bars 3. Pubs 4. Restaurants	Cigarette Smoking
(Duresso et al., 2018)	East Africa	Ethiopia	Not stated	Males and Females; Mean age 24.8; Tertiary school level; Recent graduates and undergraduate students	Khat
(Papas et al., 2012)	East Africa	Kenya	Urban setting	Males and Females; HIV-infected Kenyan outpatients who report hazardous or binge drinking.	Alcohol
(Birhanu et al., 2014)	East Africa	Ethiopia	Rural and Urban setting	Males and Females; Adolescents (14 to 19 years age group) were recruited from grade 9 to 12; Woreta secondary and high school.	1. Alcohol 2. Khat 3. Cigarette Smoking
(Embleton et al., 2013)	East Africa	Kenya	Urban setting	Males and Females; Age 10–19; Street-involved children and youth were eligible to participate if they were: 1. Between the ages of 10 to 19 and not currently enrolled in an educational institution and either 2. Spending a portion or majority of their time on the street working or roaming while returning to sleep with family or a guardian at night (child on the street) 3. Having limited or no contact with family and spending both days and nights living and sleeping on the streets or in a communally rented shelter (child of the street).	1. Alcohol 2. Marijuana/ Cannabis 3. Miraa 4. Sniffing Glue 5. Cigarette Smoking
(Ghebremichael et al., 2009)	East Africa	Tanzania	Urban setting	Females; Aged 20–44; Primary school level	Alcohol
(Ratliff et al., 2016)	East Africa	Tanzania	Not stated	Policy implementers	Heroin
(Jradi et al., 2013)	North Africa	Middle Eastern and North African	Not stated	Medical schools of the Middle Eastern and North African (MENA) regions	1. Cigarette Smoking 2. Waterpipe Smoking
(Sfendla et al., 2018)	North Africa	Morocco	Urban setting	Males; Outpatients mean age 38.3, Prison inmate mean age 30.8; Primary, Secondary, Tertiary levels; Prison inmates and male psychiatric outpatients with a previous Substance Use Disorder diagnosis.	Not specified
(Ghaddar & Ghaly, 2016)	North Africa	Egypt	Urban setting	Males Injecting Drug Users attending harm reduction trainings (the intervention) in the Egyptian Development and Human Rights Institute in Minya Governorate, Egypt	Not specified
(Ali et al., 2012)	North Africa	not stated	Not stated	Not stated	Cigarette Smoking
(Koopman et al., 2008)	Southern Africa	South Africa	Urban setting	Males and Females; Aged (33–40, 41–50, 51+); Tertiary school level; GPs practicing in private settings in Cape town	Alcohol
(Peltzer & Pengpid, 2012)	Southern Africa	South Africa	Urban setting	Males and Females; Aged (18–24, 25–34, 35–44, 45–54, 55 or more); Primary, Secondary and Tertiary levels; Hospital out-patients from five different out-patient departments: 1. Family practice 2. General out-patient 3. Cardiology 4.Diabetes 5. Ear, nose and throat and from Dispensary	1. Alcohol 2. Cigarette Smoking 3. Snuff 4. Chewing tobacco 5. Cigars
Onya et al., 2012	Southern Africa	South Africa	Peri- urban	Males and Females; Secondary school level; All students attending high schools in Mankweng District in Limpopo Province, South Africa.	Alcohol
(Cubbins et al., 2012)	Southern Africa	Zimbabwe	Rural setting	Males and Females; Ages 18 to 30 years; Target population was men and women in rural areas.	Alcohol
(Medley et al., 2014)	Southern Africa	Namibia, Tanzania, Kenya	Not stated	Males and Females; Mean age is 37.2; Primary, Secondary levels; Patients attending an HIV clinic	Alcohol
(Wechsberg et al., 2008)	Southern Africa	South Africa	Urban setting	Females, Ages 18–48; Eligible participants needed to: 1. Self-identify as Black (Xhosa speaking) or Colored (Afrikaans speaking) 2. Report alcohol or illicit drug use on at least 13 of the past 90 days 3. Report low income (i.e., less than approximately $167 US/month)	1. Alcohol 2. Marijuana 3. Cannabis 4. Cocaine 5. Ecstasy 6. Methamphetamine 7. Methaqualone 8. Tobacco 9. Crack cocaine 10. Heroin
(Scheibe et al., 2016)	Southern Africa	South Africa	Urban setting	Males and Females; Ages 23–41, Secondary level; People who self-reported to have ever injected an illegal drug and who provided informed consent, were eligible to participate	1. Heroin 2. Amphetamine-Type Stimulants
(Meade et al., 2015)	Southern Africa	South Africa	Township	Males and Females; Ages 18 years and older; The majority of Delft’s residents are Colored and Black African. The population is: 1. Relatively uneducated (with only 27% of adults completing high school) 2. Largely unemployed (with a 40% unemployment rate) 3. Poor (with 45% of households earning ≤ ZAR 600 per month, well below the poverty line)
	Methamphetamine (tik)
(Schneider et al., 2016)	Southern Africa	South Africa	Not stated	Primary Health Care Workers	Alcohol
(Watt et al., 2016)	Southern Africa	South Africa	Peri urban	Females; Ages 19–43; pregnant women and women within 12 months of postpartum	Alcohol
(Mushanyu et al., 2017)	Southern Africa	South Africa	Not stated	Adolescents aged below 20 years; Adolescent methamphetamine users reporting Methamphetamine as their primary substance of abuse in the treatment centers of Cape Town.	Methamphetamine
(Sreeramareddy et al., 2014)	Sub Saharan Africa	not stated – 30 sub saharan African countries	Not specified	Males and Females	1. Cigarette Smoking 2. Snuff 3. Smokeless tobacco 4. Pipe chewing
(Glozah et al., 2015)	West Africa	Ghana	Study occurred in private university	Males and Females; Ages between 16 and 48; Tertiary school level; Undergraduate students in a private university	Alcohol
(Stengel et al., 2018)	West Africa	Senegal	Urban setting	Males and Females; People who used drugs(injected) and Peer educators	1. Cocaine 2. Heroin 3. Crack

Appendix B.

Summary of risk factors and prevention interventions identified in the studies

Reference	Region of study	Country of Study	What are the identified risk factors of drug and substance use?	What are the types of prevention interventions identified/used in the study?
(Agaku et al., 2015)	Africa	30 African Countries	School curricula lack of inclusion	Prevention intervention identified in the current study was school based intervention focusing on school going adolescents Additionally, inclusion of tobacco prevention in school curricula, training of teachers on tobacco prevention and on-classroom educational programs were also identified Prevention policies identified in the study were smoke free school policies where it was found that countries with moderate/strongly enforced national smoke-free school policies had significantly lower odds of current smoking behavior among adolescent students than those with poorly enforced policies/no smoke free school policies The challenges on interventions identified in this study were that inclusion of tobacco prevention curricula without proper teacher training might yield suboptimal results Also, inclusion of tobacco prevention curricula without adequate access to instructional tools which might yield suboptimal results was another identified challenge The study recommended that classroom teachers and other educators should receive appropriately tailored training to enhance their participation in tobacco use prevention activities among youths Additionally, presence of smoking cessation support programs in schools could potentially help students and staff who use tobacco to quit
(Beard et al., 2010)	Africa	Low- and middle-income countries	Drug addiction	Family based preventions were identified As more parents started seeking care, Family Health International in Cote d’Ivoire started to provide children of the at risk parents health care. The national definition of orphan or vulnerable child was excluding these children making their parents unable to access support Children of sex workers were targeted in the prevention intervention
(Crunelle et al., 2018)	Africa	Not stated	Age, level of education and history of substance abuse	One of the intervention challenges stated is the over diagnosis of ADHD in SUD patients as ADHD symptoms have been found to also occur in settings, situations and stages of life without substance use. In cases where continuity of ADHD symptoms from childhood to adulthood are overlooked as well as in cases where substance-induced symptoms or withdrawal symptoms are mistaken for ADHD symptoms, ADHD over diagnosis can also occur Challenges of preventative interventions also occur when ADHD symptoms are exaggerated so as to access prescription stimulants for abuse or diversion. To circumvent such challenges, and reduce the risk of ADHD misdiagnosis, a follow-up evaluation of the ADHD symptoms during the treatment of SUD is recommended. Authors have also recommended that there should be integration of ADHD treatment into the SUD treatment. The gold standard for diagnosis of adult ADHD in patients with SUD is the use of CAADID
(Ferreira-Borges et al., 2015)	Africa	Reviewed national Alcohol policies of 46 african countries	lack alcohol and drug policies, lack of implementation and enforcement of policies, media /advertising	The identified type of prevention interventions is alcohol and substance use screening National policies of some African countries such as Fiscal (Price and Tax) Policy, Policies that affect access to and availability of drugs and substances, Policies to Reduce Drinking and Driving, Trade Policies was the focus of the study While alcohol control policies have been relatively implemented in all countries in the continent, there is still room for improvement such as adjustment for inflation of alcohol excise taxes in order to avert erosion of their effectiveness over time. Other useful preventive interventions are the restriction of alcohol marketing as a way of reducing its harmful effects on the adults and youths. Also, establishment of a low maximum BAC limit as well as strong, consistent enforcement reduce traffic injuries and fatalities Enforcement of policies and timeously adjusting them is also recommended
(Kalema et al., 2015)	East Africa	Uganda	Availability of alcohol and substances Lack of refusal skills	Individual preventive interventions were mainly identified in the study such as use of traditional general health care services and rehabilitation centers that are specialized Additionally, hospitals are the most frequently contacted places by people with alcohol related health complications Other interventions include government setting guidelines for screening and management of chronic alcohol poisoning in health centers Stricter control over the production and sale of alcohol as well as Fiscal (Price and Tax) Policy is also recommended as a preventive intervention Other preventive interventions such as licensing, pricing and taxation, age restrictions, restrictions on sales hours and days, and promotion and advertisement bans as well as a comprehensive alcohol policy are recommended as a way of restricting access to alcohol for minors and young adults Additionally, misuse prevention using information and sensitization campaigns, brief interventions for hazardous drinkers, support and treatment for addicted persons and enforcement of regulatory measures has also been recommended Concern on the Minnesota Model predominance, criticized for its limitations of focusing on addition as an incurable disease. Also, the Minnesota Model has been criticized for considering people addicts as people with pathological personalities
(Takahashi et al., 2018)	East Africa	Kenya	Not stated	Community based preventive interventions were identified in the study such as community based brief alcohol interventions, motivational talks by community health workers and former drinkers. Also, changes in the environment to restrict access to alcohol has been suggested as a way of tackling problem of alcohol use disorders. In impoverished settings, it is also suggested that CHWs can be used to implement the interventions, which could lead to good results
(Takahashi et al., 2017)	East Africa	Kenya	Gender Accessibility of alcohol and substances Availability of alcohol and substances Parental involvement in the use of alcohol and substances Peer involved in the alcohol and substance use Level of education	Community based preventive interventions, where locally available resources are used were identified in the study Alternative sources for traditional alcohol brewers and sellers should be created Interventions to mitigate alcohol consumption in the area must target social networks of alcohol consumers Changing the drinkers’ attitude toward alcohol as well as addressing the availability of unlicensed homemade brews were also suggested Limitations of the study may include underreporting of alcohol consumption of women due to stigma associated with women drinking alcohol A smaller sample size made it impossible to assess multiple l correlates of alcohol intake The amount of alcohol consumed in units was relatively difficult to measure due to unavailability of standardized alcohol content of homemade brews This study was a preliminary stage of an intervention project aimed at reducing hazardous alcohol consumption in the sub country
(Gravely et al., 2018)	East Africa	Uganda	Lack of implementation and enforcement of policies	Preventive interventions such as smoke free public places policy and its enforcement in public places, compliance to set policies as well as policies that affect access to and availability of drugs and substance have been identified Additionally, campaign for increasing awareness of the smoke-free law, establishment of a coordinated enforcement system to facilitate compliance with the smoke-free law by Ugandan Ministry of Health and Civil Society has been identified Implementation of smoke free laws may lead to changes in public support which may serve as an indicator of changing societal smoking norms
(Duresso et al., 2018)	East Africa	Ethiopia	Accessibility of alcohol and substances Availability of alcohol and substances Social pressure	Reduced substance use as well as improved incomes among stimulant consumers were reportedly reduced by a 12 -step self-help group approach This approach’s consideration as a treatment process for khat abuse may provide effective low cost options, which may be easy to organize since khat chewing is social by its nature
(Papas et al., 2012)	East Africa	Kenya	Not stated	Both individual and community based interventions such as cognitive-behavioral therapy (CBT) group health education intervention
(Birhanu et al., 2014)	East Africa	Ethiopia	Gender Participants’ place of origin Parental involvement in the use of alcohol and substances Poor academic performance Peer involved in the alcohol and substance use	Recommended preventive interventions were to foster anti substance use attitudes among individual adolescents, parents and peers through multidimensional prevention programming done by the government. Such multidimensional prevention programming may be very effective in preventing and reducing substance use patterns among school adolescents It is also recommended that for preventive interventions, content should be culturally appropriate and gender targeted, and family focused. Leveraging protective factors such as religiosity and social skills could be used as interventions that reduce substance use among adolescents Additionally, reducing negative influence of norms that favor substance use in the community domain and parents, siblings and friends’ substance use, as well as improving academic performance, and increasing perceived risk of substances use are other preventive interventions that have reported to reduce substance use among adolescents. It was also recommended that integration of the substance use education and awareness into primary and secondary curricula, strengthened with a major focus on the risk of substance use consequences could be a valuable preventative intervention Various media formats could be a valuable tool for public awareness campaigns targeting adolescents and adults especially parents, informing them of the risks of substance use. All the developed intervention programs are recommended to be culture friendly, gender based adolescent and family based programs.
(Embleton et al., 2013)	East Africa	Kenya	Socio economic background Accessibility of alcohol and substances Parental involvement in the use of alcohol and substances Peer involved in the alcohol and substance use Social background Addiction	The findings showed that there is need to integrate community, family and peers into any intervention in addition to traditional medical and psychological models for treatment of substance use dependence. Community based preventive interventions on street children, tertiary level institutions and teaching hospitals were identified
(Ghebremichael et al., 2009)	East Africa	Tanzania	Early aggressive behavior Sexual abuse Women who reported difficulty in conceiving	It is recommended that comprehensive STIs and HIV prevention programs should include screening for alcohol use
(Ratliff et al., 2016)	East Africa	Tanzania	Lack of implementation and enforcement of policies Unemployment	Harm reduction interventions and use of harm reduction policy were identified as the prevention interventions Among the drug injectors, prevention of HIV and other blood related infections were paramount Among heroin users, harm reduction was examined as a complex adaptive system, pertaining to addressing issues of drug supply, drug demand, drug use as well as production of new structures, institutions and decisions pertaining to heroin use over time To promote change, actors or components must not be excluded from participation Also, new ideas such as harm reduction must not be discouraged and communication channels must be kept open as a way of keeping some systems functional The intricacies in drug policies, leading to improved policy process can easily be understood by researchers and policy actors by using the CAS approach Understanding and adopting a CAS perspective may help to understand how to work with other systems in order to produce
(Jradi et al., 2013)	North Africa	Middle Eastern and North African	Level of Education	Identified type of prevention intervention identified is school based, where in medical schools of the Middle Eastern and North African (MENA) regions it was reported that there is general scarcity of information on how tobacco dependence and treatment is incorporated into the curriculum It was recommended that the reduction of tobacco burden could be achieved by involving physicians and other healthcare professionals in the WHO MPOWER package and interventions The WHO MPOWER strategies provide a reference model for the implementation of tobacco control strategies
(Sfendla et al., 2018)	North Africa	Morocco	Poor mental health Level of education Psychological factors (anxiety) Psychologicalfactors (depression)	For individuals with drug dependence emphasis on the need for adequate psycho-educational programs going alongside established medical treatments and social support was recommended. It is also recommended that when using integrative treatments individuals with drug dependence should be helped by outpatient centers to find social support, job opportunities, improve their level of education as well as provide adequate medical care, also taking care of their depressive symptoms.
(Ghaddar & Ghaly, 2016)	North Africa	Egypt	Not stated	Identified type of prevention intervention identified is harm reduction. The study prevention interventions focused on Male Injecting Drug Users. It was shown that the intervention effectively reduced sharing of needles/syringes, promoting condom use and voluntary testing
(Ali et al., 2012)	North Africa	not stated	Lack of implementation and enforcement of policies	Both individual prevention interventions and group interventions were identified. The prevention interventions suggested to be delivered in a one-to-one context and implemented by trained advisors or healthcare professionals Suggested interventions may offer psychological/motivational support and/or pharmacological support for tobacco use cessation Also, use of brief interventions (less than 10 min) have proved effective among tobacco users. Such interventions require minimal time and other resources yet the interventions may reach a wider population of tobacco users, helping them to recognize the impact of their habit on their health as well as leading them to seek effective treatments Smoking cessation support strategies involves both psychology- (behavioral) and pharmacology-based therapies to counter tobacco dependence
(Koopman et al., 2008)	Southern Africa	South Africa	Lack of alcohol us screening	Use of Primary Health Care Settings has been recommended as one approach that can be used to address risky behavior The study focused on General Practitioners as a group that can be used in preventive interventions Policy constraints related to reimbursement, insufficient training, and inadequate material for screening and counseling has been identified as the barriers to implementing alcohol related interventions Additionally, GPs have time constraints, making it difficult for them to focus on risky alcohol use that may lead to future patient health problems There is need for development, implementation and testing of interventions for improving the extent to which GPs address alcohol related problems in South Africa
(Peltzer & Pengpid, 2012)	Southern Africa	South Africa	Poormentalhealth, Psychological factors (stress)	Prevention interventions identified in the study are individual based interventions The most appropriate course of action for the patients is use of using simple advice and patient education materials
Onya et al., 2012	Southern Africa	South Africa	Accessibility of alcohol and substances Availability of alcohol and substances Participants’ place of origin Adults drug users adult drug dealers antisocial behavior among adults in the community	The identified preventive intervention targeted secondary school students Suggested prevention programmes should promote adolescents’ prosocial behavior affirmation by the community as well as improving the perceptions of adolescents about the state of their neighborhood Reducing substance use as well as minimizing adults’ antisocial behavior in the community was also identified as a vital preventive intervention to prevent or delay drinking among adolescents Alcohol prevention strategies needed to tackle both intrapersonal risk factors for underage alcohol use and structural risk factors Future research direction to consider exploring the community-level covariates of out-of-school adolescents’ use of alcohol
(Cubbins et al., 2012)	Southern Africa	Zimbabwe	Age Gender, Ethnicity, Participants’ place of origin, Level of Education, Marital Status, Employment Having no religious affiliation	Community Popular Opinion Leader (CPOL) Community-based Intervention was identified Deteriorating economic situation in Zimbabwe led to insufficient exposure to the community level intervention due to absence seeking employment opportunities elsewhere There was a general decline of alcohol use in intervention and control sites, possibly due to economic effects overshadowing the ability of the intervention to show any effects Intervention messages focused primarily on HIV with alcohol consumption being a secondary focus. There was a general decline of alcohol use and alcohol abuse at relatively equal levels at both the CPOL intervention and control sites Suggested future research must be done to understand more fully how ethnic differences contribute to substance use behaviors in Zimbabwe.
(Medley et al., 2014)	Southern Africa	Namibia, Tanzania, Kenya	Gender Incomplete adherence to medication high risk sexual behaviors	Identified prevention intervention was clinic level intervention targeting People living with HIV focusing on education on alcohol and substances Focusing on changing the social norms around alcohol, changing legal and policy frameworks around alcohol use and substance- abuse treatment was also identified Given the widespread availability of alcohol in SSA, individual-level counseling strategies must be accompanied by community- and structural-level interventions Biological marker to determine alcohol consumption may be used in future studies focusing on ART adherence and sexual risk behavior among PLHIV in SSA Operational research using biological markers may also determine the best models for screening patients for alcohol use Biological markers based operational research may also be ideal for delivering targeted alcohol reduction counseling to patients reporting current alcohol use.
(Wechsberg et al., 2008)	Southern Africa	South Africa	Ethnicity	Identified preventive interventions were individual interventions focusing on education on alcohol and substances, specifically using the Cape Town Women’s Health CoOp. It was recommended that interventions be grounded in social psychological theory Additionally, it was also recommended that interventions must include women-only sessions led by peers; be culturally sensitive; and include both behavioral modeling and skill-based approaches Limitations of the study was that sample size was small and participants were selected through targeted outreach in their communities Also, responses of participants may be modified due to the belief that it may help or hinder them through the social welfare, health, or criminal justice systems
(Scheibe et al., 2016)	Southern Africa	South Africa	Gender Accessibility of alcohol and substances Race	The study raised concerns that people using drugs are criminalized and experience harassment, arrest without cause and other rights infringements in most instances, which may be barriers to safer injecting and to accessing health services There is need for increased access to sterile injecting equipment as well as education around safer injecting practices PWID interventions have been shown to reduce the risks of HIV infection, although more interventions building on established HIV infection risk reducing behaviors as well as sensitizing pharmacy staff of the consequences of preventing access to sterile injecting equipment are needed Future research direction to include HIV testing procedures and provide participants with their tests results Interventions of needle and syringe programmes, and targeted information and interventions around effective needle and syringe cleaning and overdose prevention were recommended It is recommended that when developing policy and programmes for PWID in South Africa, broader social issues must be considered given the high prevalence of sex work, unemployment, homelessness, and the vulnerability of females who inject drugs and PWID from previously disadvantaged communities
(Meade et al., 2015)	Southern Africa	South Africa	Socio economic background Accessibility of alcohol and substances Availability of alcohol and substances Participants’ place of origin Social background	Individual interventions, linking users to treatment centers were identified Methamphetamine use in the social environment was perceived as normative and it was readily available. Also, methamphetamine users wanting to quit attributed to drug-using peer networks as a major contribution to relapse, hence the only way to quit was to leave the community. It was suggested that community based interventions must be developed and tested Motivational interviews may be a helpful strategy to address barriers to treatment initiation given the first time willingness of participants to talk about their level of education and its impact on their lives Uptake of drug treatment among methamphetamine users may be improved by reduction of barriers to treatment initiation, increase awareness of available treatment options, understanding of addiction as a treatable medical condition as well as reduction of negative beliefs about treatment effectiveness Additionally, continuing care services to prevent relapse must be done considering the lack of support for recovery and abstinence in communities where methamphetamine use is normalized and treatment uptake is low The current mixed methods study reported daily drug use, high addiction severity as well as the fact that few had sought treatment Qualitative data indicated that both motivators for and barriers to treatment were prominent. It was recommended that interventions must seek out users, foster motivation, and link them to treatment. Elimination of barriers may also be ensured through community education about addiction
(Schneider et al., 2016)	Southern Africa	South Africa	Scarcity of counseling skills Lack of clarity for PHCW regarding guidelines on alcohol use when on ART	The identified prevention intervention is the use of PHCW assessment and dealing with alcoholics. It was suggested that there is need to train and empower them on the assessment and dealing with alcoholics The study also recommended integration of services, improvement on the levels of information as well as addressing misinformation It was recommended that more information needs to be made available especially to clinic attendees as well as correcting all misinformation pertaining to consumption of alcohol while in ART ARV adherence among alcohol drinkers could be improved via interventions that correct alcohol related interactive toxicity misinformation. Additionally, ART programmes need to have alcohol reduction strategies incorporated. In order to address substance abuse in PLHA, the study indicated the need for additional information and training of the service providers Drawing up of clear prevention and treatment guidelines for PHCWs and patients at ART clinics concerning alcohol consumption as well as for treatment of naïve patients was also suggested. The study also anticipated making HIV and AIDS service users and providers more attentive to potential alcohol abuse problems as well as generating public and health policy makers’ awareness of the harmful effects of alcohol consumption for treatment-naïve HIV patients and those taking ARVs.
(Watt et al., 2016)	Southern Africa	South Africa	Attitudes and perceptions Misinformation	For pregnant women, there is need to deliver accurate information about the dangers of fatal alcohol exposure, through trusted and reliable information sources A powerful influence of social networks and modeling behaviors has been reported, thereby necessitating delivering accurate information to the community at large essential so as to curb the high rates of FASD in South Africa’s Western Cape Province The study highlights the need to address knowledge and attitudes toward alcohol consumption during pregnancy
(Mushanyu et al., 2017)	Southern Africa	South Africa	Not stated	Development of effective prevention programs for prevention of methamphetamine abuse among adolescents require an understanding of how adolescents initiate methamphetamine abuse Awareness programs aimed at reducing MA abuse were suggested to target adolescents so as to reduce any future problems associated with early adolescence drug use.
(Sreeramareddy et al., 2014)	Africa	30 Sub-Saharan African countries	Age Gender Level of Education Marital Status Unemployment Area of residence Occupation Employment status Catholic or no religious affiliation	Identified prevention interventions included elimination of the root causes of smoking such as illiteracy and poverty Adoption of the FCTC was suggested Adoption of the FCTC provides for a ban on tobacco advertising, promotions, and partnerships, warning labels on tobacco product packages, measures to prevent exposure to second hand smoke, and increased taxation Focus was also given to Fiscal (Price and Tax) Policy, Trade Policies as prevention interventions Collection of updated tobacco use data may provide a complete scenario of tobacco use in the SSA region Prevalence of smoking among women was much lower than in men Tobacco use social patterns among women were reportedly similar to those of men Tobacco control strategies were suggested to target the poor, uneducated or those with minimal education levels, agricultural and other unskilled workers, considered to be the most vulnerable social groups in sub-Saharan Africa.
(Glozah et al., 2015)	West Africa	Ghana	Low self esteem	The identified prevention intervention was life Skills training where the Alcohol Abstinence Self Efficacy Scale was used The study recommended AASES further assessment in larger surveys and for a longer period in longitudinal studies using a larger sample size Slight to moderate differences in alcohol abstinence self- efficacy by age, gender, stream, and type of residence were observed although these differences were not statistically significant.
(Stengel et al., 2018)	West Africa	Senegal	Poverty	The types of preventive interventions identified in the study include use of peer education facilitators/educators especially those that were using drugs Young people and women were seen as having limited contact with peer educators, who were mostly older men It was suggested that peer educators should be diversified in terms of age and gender representation among people who use drugs, who might have different needs than those currently acting as peer educator It was also suggested that future peer educator recruitment and outreach should be focused on a gender inclusive approach considering the higher rates of HIV among women who use drugs Peer education and outreach initiatives require sustainable financing and collaboration