Social and structural determinants of youth alcohol use in Tanzania: The role of gender, social vulnerability and stigma

Abstract

Adolescent alcohol use remains an under-addressed population health issue across Africa. Although the literature explores the intersection of alcohol use and vulnerability to HIV and AIDS, there is limited evidence on the gendered uptake and use of alcohol among adolescents. Capturing adolescents’ voiced experiences about the societal influences shaping their alcohol usage is essential for identifying contextually relevant interventions to reduce their vulnerability to alcohol and related risky behaviours, such as unsafe sex. We conducted qualitative research in urban Tanzania, including key informant interviews, systematic mapping of alcohol availability, in-depth interviews with adolescents in and out of school and adults, and participatory methodologies with adolescents ages 15–19. The findings described here were drawn from the participatory methodologies (n=177); and in-depth interviews with adolescents (n=24) and adults (n=24). Three key themes emerged: (1) boys’ increased social vulnerability to alcohol consumption; (2) the ways in which stigma shapes girls’ alcohol usage; and (3) how gendered perceptions of alcohol use reinforce societal inequalities. There exists an urgent need to address the social and gendered vulnerabilities of youth in Africa to the uptake and use of alcohol, and identify interventions that reshape notions of masculinity increasing boy’s vulnerability to use.

Introduction

Adolescent alcohol use in low-income countries remains a relatively under-researched, and therefore under-addressed, population health issue. Recent evidence suggests growing consumption and heavy use of alcohol across sub-Saharan Africa as countries become more developed and transition from consuming homebrewed alcohol primarily at ceremonies, to use being influenced by intensive marketing by commercial alcohol companies which may increasingly focus on youth (Viner et al., 2012). Limited evidence from South Africa suggests a decreasing age of alcohol initiation, and possible differences in rural versus urban use (Onya et al., 2012; Peer et al., 2013). A growing body of literature from sub-Saharan Africa is beginning to document the ways in which alcohol intersects with HIV and AIDS (Fisher et al., 2007; Ibitoye et al., 2019; Kalichman et al., 2008; Mbulaiteye et al., 2000; Page & Hall, 2009), or more specifically unsafe sexual behaviours among youth who have been consuming alcohol (Njue et al., 2011; Njue et al., 2009; Zablotska et al., 2006). However, significant gaps remain in our understanding of the patterns of uptake and use among youth, and how gender and other societal norms intersect with, or are reflected in, their patterns of use. There is a critical need to understand the ways in which gender shapes young people’s vulnerability to using alcohol and engaging in related high-risk behaviours, such as unsafe sex and subsequent infection with HIV.

A deeper understanding from the perspective of young people themselves about the role of alcohol in their lives, including the familial, peer and societal pressures they experience to use or to avoid alcohol, is essential for ascertaining what types of interventions may be needed to delay their uptake, or mitigate the potential harms they encounter from consumption. This is particularly important in urban contexts where studies are beginning to document the intense environmental exposures that young people may encounter to commercial and home brewed alcohol sales and advertising (Leslie et al., 2015; Sommer et al., 2013b; Swahn et al., 2011). This article describes one such effort to contribute to filling this gap in the literature on the gendered experiences of adolescent alcohol initiation and use through the conduct of qualitative and participatory research with adolescent boys and girls in Dar es Salaam, Tanzania’s largest urban environment, and with a range of adults who intersect in their daily lives. The implications are relevant as well for better understanding the relationship between gendered HIV risk as a result of gendered alcohol consumption among youth.

Although data on youth alcohol use is scant in most sub-Saharan African countries, the limited evidence from Tanzania indicates that in 2010 the prevalence of ‘binge’ drinking among males ages 15 and older was 21.2% and for females, 12.7% (Swahn et al., 2011; World Health Organization, 2018). These findings were supported by a study conducted in northern Tanzania in 2012–2013 among youth aged 15–24 years old which found that alcohol use among males was significantly higher (47–70% ever users and 20–40% current users) as compared to females (24–54% ever users and 12–47% current users) (Francis et al., 2015). In the latter, there was indicated to be a preference for bottled beer among both females and males, a preference for wine among females, and of locally made spirits for males. Both males and females reported initiating alcohol consumption at weddings, funerals, or other ceremonies, with bottled beer and local brew (ranging from 2–8% alcohol content in beer, up to 55% in spirits) the most common first drink for both genders. A 1968 Intoxicating Liquors Act aimed at regulating the production and use of local brews, and there exists a minimum legal age of drinking and purchasing of alcohol of age 18, although there exists little evidence of enforcement (Ibitoye et al., 2019). More specific data on the actual patterns of use by adolescent boys and girls (ages 15–19) is lacking, and there remains insufficient understanding of the societal and gendered pressures that may increase adolescent uptake and use or alternatively serve to protect young people from initiating use or engaging in heavy use.

In exploring the relevancy of understanding youth vulnerability to alcohol use, Hardgrove et al. (2014) describe how four contextual aspects of youth’s lives in low-income countries serve to create and enhance youth vulnerability to negative health and social outcomes; these include ‘poverty, inequality, social exclusion and hazardous environments’. In applying this lens to the use of alcohol by youth in Dar es Salaam or other dense urban environments in sub-Saharan African countries undergoing development, there are likely to be large numbers of youth experiencing three if not all of these interconnecting contextual realities, occurring in tandem with the confusion and hence vulnerability that youth may feel about their own changing bodies, from the shifting social dynamics that occur as families, peers and communities respond to youth sexual and social maturation, and from the gendered performances that are expected as maturation becomes more evident. Given the potential sensitivity of exploring youth alcohol drinking patterns in contexts where use under a certain age may be illegal, or cultural traditions may sanction youth alcohol consumption, the use of qualitative and participatory methodologies is a particularly effective way to engage with young people in understanding their experiences.

Methods

Study aim

The overall study examined the social, community and environmental context of adolescent alcohol initiation and consumption in urban Tanzania, the gendered aspects of consumption and the subsequent experiences of risky sexual behaviour. This paper focuses in particular on the aim to better understand the gendered dynamics around alcohol uptake and use among adolescents in and out of school in urban Tanzania.

Research design

The research design and setting are extensively described elsewhere, but consisted of a comparative case study using multiple methodologies: 1) formative key informant interviews with key stakeholders; 2) systematic mapping of alcohol density outlets and advertising around schools and youth centres; 3) participatory activities with groups of in and out of school adolescent girls and boys; 4) in-depth interviews with adolescents; 5) in-depth interviews with adults (e.g. alcohol vendors, police, teachers); and 6) concluding key informant interviews with key stakeholders (Sommer et al., 2020). The use of participatory methodologies with young people was critical for capturing their lived experiences with alcohol and alcohol-related sexual interactions, along with their recommendations for how to address youth alcohol use and related unsafe sex. Participatory methodologies emphasize an equalizing and dynamic exchange between researchers and participants, and the participatory process empowers young people, enabling them to feel like researchers of their own lives (Mitchell & Sommer, 2016).

The study setting included four sites across Dar es Salaam, a city of 4.3 million in Tanzania (World Population Review, 2020). The sites differed by distance from the city centre, industrial and residential aspects, and the socio-economic status of the population (see Table 1). Each site included: one secondary school (including a sample of male and female students) and youth centres and vocational training centres (including a sample of out of school male and female youth). The youth in and out of school were aged 15–19.

Table 1:

Four Sites in Dar es Salaam

Ilala	City Centre
Temeke	Industrial Area
Tandale	Informal settlements
Bunju	Peri-urban, furthest from centre

Sample and data collection

The research assistants, consisting of four Tanzanians (two young women, two young men), met with separate groups of female and male adolescents (total n=177; n=10–12 same sex adolescents per group) to conduct participatory activities once a week over a period of four weeks. In each of the four sites, there was one male group and one female group of students, and one male and one female group of out of school adolescents (ages 15–19), for a total of four groups per site. Both in and out of school adolescent were sampled given the expectation that they may engage in differing patterns of alcohol consumption. Adolescents were purposively sampled for inclusion (e.g. lower versus higher economic status, differing academic abilities, differing religious backgrounds). The groups would meet in confidential spaces (empty rooms away from other people), with informed consent requested and provided before data collection began. The weekly participatory group meetings enabled the research team to build trust with the young people, and to explore increasingly sensitive topics with each meeting. The groups would meet in confidential spaces (empty rooms away from other people), with informed consent requested and provided before data collection began. The research team also conducted in-depth interviews with a smaller sub-sample of male and female adolescents (n=24), and with male and female adults who intersect in adolescents’ lives (n=24).

We draw on three of the qualitative methods for the findings described in this paper:

(1). Participatory Activities (Week 3): Gendered Drinking Patterns

As part of a series of participatory activities conducted in week 3, the adolescents (in separate groups, girls working with female research assistants and boys working with male research assistants), first broke into small groups to brainstorm and list the drinking behaviours of, and pressures on, girls versus boys in society (separate columns for girls and boys). Next, the groups reported out and created a list on the blackboard. Additional probing was done, with content added to the master list and a larger discussion conducted. Data consisted of youth written lists, and careful note-taking of the master blackboard lists and group discussions. Digital recording was not used given the noise-related challenges of conducting research in tin-roofed structures during the rainy season, however careful transcripts were written up from extensive note-taking conducted by the research assistant pairs for each session.

(2). In-Depth Interviews with youth:

A sub-sample of adolescents (girls and boys) were invited to participate in individual in-depth interviews with a same-sex research assistant. The interviews enabled a deeper exploration of the topics discussed in the group activities, and the possibility of sensitive information shared more comfortably (in a confidential way) one to one rather than in front of a group. The interview topic guide covered a range of issues related to adolescent alcohol use and sexual encounters. The questions of particular relevance for the findings described in this paper included young people’s use of alcohol, how this might differ by age and gender, how peers influence each other to use, other pressures to drink, and perceptions of adolescents who consume alcohol.

(3). In-Depth Interviews with adults:

A sample of adults (males and females who were independent of the adolescent participants) were invited to participate in individual in-depth interviews. The interviews enabled an exploration of adolescents and alcohol from the perspective of adults who intersect in and potentially influence Tanzanian adolescents’ lives (e.g. parents, teachers, shopkeepers, alcohol vendors, health care workers, religious leaders, school guards). The interview topic guide covered a range of issues related to adolescent alcohol use and sexual encounters. The questions of particular relevance for the findings described in this paper included perceptions of young people who consume alcohol, how this might differ by age, gender, and in-school versus out of school youth, influences that shape young people’s initiation of alcohol use, and cultural and gendered traditions around alcohol use.

Institutional Review Board approvals were acquired from Columbia University Medical Centre (CUMC), and in Tanzania, Muhimbili University of Health and Allied Sciences IRB, the National Institute of Medical Research IRB, and COSTECH. Informed consent was requested of all participants before data collection began, and the study received a waiver of parental consent given the importance of young people feeling they could openly describe their experiences within a context that includes some societal sanctioning of adolescent alcohol consumption. We received approval from all four IRBs for a waiver of written consent given the potential illiteracy of some adolescent and adult participants.

Data analysis

As described in-depth elsewhere (Sommer et al., 2020), the data consisted of fieldnotes, interview (key informants and in-depth interviews) and participatory activity transcripts, maps drawn and labelled by the adolescents, written stories, lists created (and sometimes ranked) by groups of youth, group discussion transcripts, systematic mapping information of alcohol in the sites, and photos with their written summaries. The latter are beyond the data that were analysed for the purposes of this paper, however the fieldnotes were also incorporated within the analysis along with the relevant participatory data and interview transcripts. The data were all coded and analysed by the Tanzanian research team with oversight from the larger investigative team. This included NVivo coding of the interview transcripts and matrices developed for analysis of the participatory activities.

We conducted thematic analysis on the transcripts from the participatory activities and the notes from the ethnographic observations. First, all of the participatory transcripts were read by a member of the research team and a preliminary list of codes was identified. Next, the four research assistants independently read through a set of transcripts and placed the responses obtained from participants into matrices containing the different codes. Discrepancies were resolved by discussion until consensus was reached and the matrices were revised to minimize overlap of codes and to highlight and cluster overlying themes. Once the matrices were finalized, two research assistants independently coded all remaining transcripts. Notes from ethnographic observations were also analysed for common themes and were used to triangulate the findings from the participatory activities. Findings were triangulated through the analysis of data from multiple methodologies.

The thematic areas that emerged from the described methods included the following: 1) Boys’ increased social vulnerability to uptake and consumption of alcohol; 2) The ways in which stigma shapes girls’ alcohol usage; and 3) How gendered perceptions of alcohol use reinforce societal inequalities.

Results

The four sites across Dar es Salaam included a diversity of ethnic backgrounds, socioeconomic status, and education levels among youth (both those in and out of school) and adults. However, there were remarkably similar commonalities found across all four locations in terms of the thematic issues that arose in relation to the gendered dynamics and vulnerability around alcohol use. A prior publication describes in-depth the ways in which alcohol advertising is promoted to youth, particularly to males, and how the concentrated presence of advertising and alcohol outlets (bars selling beer, spirits and homebrew) influence many youth in their residential and school-going neighbourhoods (Ibitoye et al., 2019).

Boys’ increased social vulnerability to uptake and consumption of alcohol

In describing how drinking behaviours are different for boys and girls within their communities, the young people across all four sites expressed numerous societal structures, scenarios, and social and developmental influences that appear to significantly increase adolescent boys’ social vulnerability to both initiating alcohol use and to consuming alcohol more frequently (and heavily) as compared to adolescent girls. A key enabler appears to be the ways in which parents or guardians relate to sons (versus daughters) both in terms of the monitoring of or effort to control their behaviour, along with the masculinity norms around alcohol use being imparted generationally to boys. Both boys and girls reported the availability of bottled beer and homebrew at local ceremonies; with girls favouring lighter drinks with lighter alcohol content, and only boys describing the consumption of spirits (or hard alcohol).

In terms of the societal or familial structures influencing use, numerous adolescent girls and boys described how boys are much more likely to drink alcohol because their comings and goings are not monitored by parents and guardians to the same extent that girls are, and because of the much greater freedom that boys are allowed around their social interactions and behaviours. As young people in different sites described:

Parents are lenient with boys…as early as the age 15 they are free to make their own decisions …They can join friends and easily be influenced to drink alcohol.

[out-of-school girls, Temeke]

Girls of under 18 are not free and are monitored by their parents so they are not free to go out with their friends or far from home because they are under strong supervision.

[out-of-school girls, Bunju]

In addition, boys were described as having many fewer chores than girls at home, and therefore having more freedom to engage with others who might influence their use of alcohol. There was also articulated to be a modelling of alcohol use – or rather – masculinity norms being conveyed to boys from fathers around the uptake and use of alcohol which created scenarios encouraging initiation and use.

Boys spend most of their time with their fathers who drink alcohol…they go to bars together and that may cause them to drink.

[in-school boys, Temeke]

[Boys] start drinking early…because of freedom they have…they are less protected… a father may also take his son to the bar where he will be drinking, so that will make that boy feel like drinking.

[in-school boys, Ilala]

The bars described ranged from those selling commercial alcohol to local home brew. The intersection of the modelling of alcohol use and masculinity norms also arose in the descriptions of peer pressures on young people to drink, with a few boys articulating scenarios where if a boy were to say no to an offer of alcohol from his male peers, ‘they tell him he wants to be a girl’ (in-school boys, Tandale). This was similarly stated by in-school girls in Bunju, who explained that the peer pressure on boys is linked to the enactment of manhood, with a boy who refuses to drink being told, ‘a man is supposed to trust himself in the decision…if you refuse, you will be like a gay or a girl.’ In addition, a number of youth explained how boy’s freedom enabled staying out later hours with peers without being punished, as compared to girls, and hence a greater likelihood of exposure to peer pressure around using alcohol. In contrast, some of the youth described how socializing in groups was a ‘rare thing’ for girls (in-school girls, Temeke), and hence girls were perceived as being less exposed to (or more protected from) pressure to consume.

Pressures on adolescent girls to drink alcohol were also described by the youth as existing, but as being less likely to come from female peers and more likely from boyfriends who were eager to have girls drink in order to pressure them for sex, or alternatively, occurred in scenarios in which girls felt the need to drink to demonstrate their love for a boy (or man), or were ‘seduced’ through alcohol by older men wanting sex. An additional perspective on gendered use arose during the interviews with adults, many of whom described how a youth needs to be ‘independent’ within the family before he or she is perceived as old enough to drink. This translated into an increased vulnerability for boys, who many young people explained become independent earlier than girls, with the perception that boys were more likely to begin earning wages during adolescence. In contrast, adolescent girls were described as being less likely to drink because they do not have money, and as less likely to be financially independent or earning wages during adolescence. However, one result of girls’ lack of money as described by both adolescents and adults, articulated how girls were more likely to drink alcohol with boyfriends, given the desire or need for money, something that boys or men would provide.

Lastly, there were observations made by youth about the natural course of adolescent development that may serve to enhance boy’s vulnerability to alcohol use in comparison to girls, with male students explaining:

Girls grow [up] early which makes them be close to their parents. Girls are entering puberty at around age 9…so it makes them stay at home and it’s harder to try new things like drinking. Someone of age 9 cannot stay out of the house compared to a boy that is 15 when puberty comes.

[in-school boys, Temeke]

This would suggest that the timing of adolescent development may serve a protective function for girls around alcohol use, even if girls earlier maturation may increase their vulnerability to other risk behaviours, such as sexual pressures.

Of importance to note is that not all ethnic groups in Tanzania consume alcohol as part of their cultural activities, and that religious beliefs also emerged, particularly in the interviews with adults, as influencing perceptions about the appropriateness of alcohol use by adolescents (sometimes overriding traditional beliefs that condone youth alcohol use). Therefore, the findings described above in relation to parents’ leniency around boy’s usage, or the introduction of alcohol by fathers to sons, should not be interpreted to be universal across all of Tanzania.

The ways in which stigma shapes girls’ alcohol usage

In contrast to the ways in which Tanzanian societal dynamics appear to be increasing adolescent boy’s vulnerability to alcohol use, on-going stigma around adolescent girl’s use of alcohol appears to be serving as a protective factor against consumption, albeit one that also serves to reinforce gendered inequalities in the society (discussed below). The existence of stigma around girl’s alcohol use emerged out of the descriptions from both adolescents and adults around perceptions of girls’ alcohol use being related to their moral codes, as reflecting on their upbringing and thus their families’ reputations, and as reflective of girls’ abilities to fulfil societal expectations around marriage and fertility.

Many adolescents, both boys and girls, described how society perceives girls who consume alcohol, as compared to boys, as having looser morals:

[Girls] drink less because they fear that people will look down on them.

[out-of-school girls, Tandale]

You cannot find [girls] drinking in public places…they will be seen as uncontrolled and like they do not have manners.

[in-school boys, Ilala]

This quote stood in contrast to the perception that ‘even if [boys] are drunk, no one will look down on them’ [out-of-school girls, Tandale]. An in-depth interview provided more specificity to the view of girls who drink:

The community likes to say that a girl who drinks is a prostitute and promiscuous… when a girl drinks she is not in her right state of mind and will have sex with anyone.

[in-school boy, Temeke)

This was further reinforced by another in-school boy who explained during an interview that girls who drink are perceived by the community as those who ‘lack moral conduct or discipline’ and as ‘not respecting herself.’ This fear of societal negative perceptions of them as immoral or as promiscuous may be serving to prevent many girls from initiating or using alcohol.

The stigma around girls drinking also emerged in relation to familial dynamics, with girls fearing they would disappoint or upset their parents, or having their behaviour reflect badly on the family if they were to be found using alcohol. As out-of-school girls in Temeke explained, ‘[Girls] are scared what their parent’s impression of them will be if they are caught drinking.’ This perception similarly arose among boys, such as the below explanation:

[Girls] do not show off their drinking behaviour because they are scared of the negative perception from the community because girls are raised not to drink alcohol.

[out-of-school boys, Bunju]

More specific concerns arose during the in-depth interviews, such as an out of school girl in Temeke who explained that if they see a girl drinking and advise her to stop and she doesn’t, they assume she is ‘from a family that drinks…that it’s normal [for her] and she can’t control it.’ However, the real burden of the stigma (or blame) falling on the girls themselves who might be seen drinking was illustrated by an explanation of the possible consequences:

If a parent or any family member finds a girl drinking, it leads to a parent making decisions such as telling the girl that she is no longer wanted in the family….they may even want her to get married, to prevent her bringing shame to the family; …or if it is a rural area, he may tell her to go and look for a housemaid job.

[in-school girl, Ilala]

Finally, there were numerous implications made about the suggested downfall in a girl’s future in relation to marriageability and motherhood if she were to be seen drinking in adolescence, both markers of womanhood in the larger society. As two different groups of boys articulated community perceptions of girls who drink:

Girls who drink are those who have lost their visions…see no future.

[in-school boys, Bunju]

[Girls] cannot get married if involved in drinking.

[in-school boys, Temeke]

A number of adults underscored this perception, with one adult in Bunju explaining, ‘girls are supposed to take care of the family…so it’s a dangerous sign for the future [if she is seen drinking].’ However, another Bunju adult suggested a shift in gendered alcohol dynamics, perhaps related to societal modernization, explaining that ‘in the past, no one would want to marry a woman who was a drunkard but now someone will marry her.’

Additional rationales emerged as well, as one in-school girl explained in Tandale, ‘[girls] don’t easily let themselves drink until getting drunk because they are cautious with their future.’ However, this seemed to also reflect many girls and adults expressed fears of being raped if they were to drink, or drink excessively. Numerous comments were made such as the below:

[Girls] fear to drink because they…will be influenced to do sex or will get dragged by someone along the street if they are drunk.

[in-school girls, Bunju]

[Girls] always fear that if they get drunk, they can be raped, and end up pregnant, and if they are students, they cannot go on with their schooling.

[in-school girls, Ilala]

The implication of the latter is that in Tanzania, when girls get pregnant (a potential consequence of rape), they have to leave school. This also serves to reinforce the notion that girls are responsible in some way for getting raped, and for any subsequent removal from furthering their education. However, during an interview, an out of school girl in Tandale indicated that, ‘girls [in her area] live by selling their bodies so it’s normal to drink.’ This suggests another population at significant risk of unsafe sex, infection with HIV, and sexual violence in relation to alcohol.

How gendered perceptions of alcohol use reinforce larger societal inequalities

An overarching larger implication of the perspectives of a number of adolescents and adults was the idea that adolescent girls are lesser than boys in both social and biological ways, as reflected by the intersection of adolescent girls and alcohol. In terms of the social ways in which they are perceived to be inferior (or less equal to boys), a number of groups, both in and out of school youth, articulated the concerns of family and society around girls:

Girls are prohibited by their parents to go out as they are not trusted.

[out-of-school girls, Bunju]

When they set them free, they can easily involve into sex and get pregnant so it is not likely that parents will set them free at an early age. They cannot make their own decisions. Example, they cannot come home whenever they would like.

[out-of-school girls, Temeke]

In contrast, boys were described as being superior in their ability to manage themselves, and their drinking behaviours, ‘Boys are trusted a lot by parents and never followed by parents…’ [out-of-school girls, Bunju]. A number of boys, in turn, had explanations for why girls are in fact not trusted or are perceived to be socially inferior (or less equal) in relation to alcohol use, ‘[Girls] are easily tempted after drinking, tempted to do things like sex’ [in-school boys, Bunju]. Numerous youth explained how girls were perceived as unable to make decisions, and hence not trusted when it comes to alcohol use.

Additional explanations from some adults also reflected a social construction of this perception of girls as being, or perceiving themselves, as lessor:

If I observe a boy’s behaviour, he is composed with a sense of confidence, as he believes he can do anything. But a girl is someone who sees she can’t do things and is based on an inferiority complex or fear of community perceptions of her if she drinks.

[in-depth interview, male local government, Ilala]

Of importance, the perception of girls as being inferior (or less equal to boys) went beyond the social to being explained as actually biological or physiological in origin, the implication of which is significant for reinforcing larger societal inequalities and hindering girls’ opportunities. The explanations came from both youth and adults:

After drinking, [girls] end up removing their clothes, they are psychologically distorted after drinking alcohol.

[in-school boys, Bunju]

Once a girl drinks, her mind melts away, which is different from men.

[in-depth interview, in-school boy, Bunju]

Men are created differently, they drink without worrying.

[in-depth-interview female teacher, Ilala]

The perspective that somehow girls are psychologically less able than boys to manage alcohol, or inferior, was expressed in many of the sites, and went beyond their ability to drink alcohol to suggestions that girls are unable to make decisions (in comparison to boys), with potential ramifications for controls being issued over their lives far beyond alcohol use or the close monitoring of their social lives.

Discussion

The findings described here sought to explore the relevancy of understanding youth vulnerability to alcohol use, including how contextual aspects of youth’s lives in low-income countries serve to create and enhance youth vulnerability to negative health and social outcomes (poverty, inequality, social exclusion and hazardous environments) (Hardgrove et al., 2014). In applying this multi-contextual lens to the gendered use of alcohol by youth in Dar es Salaam, Tanzania, we explored how may be experiencing these interconnecting contextual realities in tandem with the confusion and hence vulnerability that they feel about their changing bodies, the shifting social dynamics that occur as families, peers and communities respond to youth sexual and social maturation, and the gendered performances that are expected as maturation becomes more evident.

More specifically, the larger participatory and qualitative study of adolescent alcohol use and related unsafe sex in Dar es Salaam, Tanzania, from which the findings in this paper emerged, sought to understand the structural and environmental influences shaping adolescent alcohol initiation and use in a large urban African context. The findings in this paper revealed important gendered dynamics around the use of alcohol among young people, including the differing experiences of adolescent girls and boys, the increased vulnerability of adolescent boys to alcohol uptake and use, the ways in which stigma around girls drinking alcohol is problematic yet may serve a protective function, and how perspectives on gender and alcohol use may reinforce larger societal inequities, including gendered vulnerability to unsafe sexual behaviours. The framework provided by Hardgrove et al. (2014) indicating the intersecting nature of poverty, inequality, social exclusion and hazardous environments as shaping youth vulnerabilities in low-income contexts, while not fully explained in the findings described here, nevertheless provides an important conceptualization of the ways in which context serves to enhance youth vulnerability. The adolescents and adults who participated in this study came from a range of socioeconomic statuses, and represented both youth in and out of school, yet similarities were revealed across this diversity of experience and social or educational status in relation to vulnerability and gender. Additional findings from the larger study describe the ‘hazardous environments’ in which youth find themselves in relation to alcohol, given the heavy presence of alcohol sales and advertising in their daily lives, including around homes, schools and youth centres (Ibitoye et al., 2019).

The finding that adolescent boys are at increased vulnerability to the uptake and use of alcohol, is supported both by previous studies conducted in Tanzania (Sommer et al., 2013a; World Health Organization, 2018), and studies conducted in other low-income countries (Bohmer & Kirumira, 2020; Mugisha et al., 2003; Njue et al., 2011; Scandurra et al., 2016). Although the body of literature around boys’ and young men’s use of alcohol is generally described in the context of sexual violence and/or HIV risk behaviors (Jewkes et al., 2009; Strebel et al., 2006), earlier work from Tanzania highlighted the ways in which parental modelling (Njue et al., 2011; Sommer et al., 2013a), and in this study, father modelling in particular, is serving to increase boy’s uptake and potentially heavier use of alcohol. In addition, the notions that boys, seeking to enact and prove their manhood to peers, girls, and fathers should drink, that they are better able to handle alcohol than girls, and that many parents trust them to make their own decisions around alcohol use, all serve to increase boys’ vulnerability to initiating alcohol use and heavier consumption (both stronger alcohol and more frequent use of alcohol). Such findings have important implications both for better understanding the nature of boy’s vulnerability in such contexts, and also for potential interventions that might seek to shift social norms around masculinity and parenting dynamics.

The indication that stigma around girl’s use of alcohol in society serves both a discriminatory and protective function, is also of great importance. Although few studies have explicitly explored gendered perceptions of alcohol use in sub-Saharan Africa or other low-income contexts, findings in relation to the much more accepted perception that boys and men should be drinking (versus girls) have been highlighted (Strebel et al., 2006). However, one study in Zambia did suggest girls are more vulnerable than boys (Swahn et al., 2011). More commonly, on-going stigma in relation to girls’ behaviours around alcohol serves as a marker of gendered norms within society that reinforce what is expected of a ‘good girl.’ In this study, the finding that a girl who drinks may be perceived as unable to get married, or is unfit for childbearing, is reminiscent of similar ‘good girl’ indicators in societies around the world that aim to control a girl’s behaviour. This includes, for example, the perception that girls are to blame if raped or victims of sexual violence (Suggs, 1996). In Tanzanian society, as in many sub-Saharan African countries, demonstrating fertility is paramount to representing womanhood (Beckham et al., 2015; Jewkes et al., 2005), and thus the notion that a girl caught drinking may be untrustworthy or a bad future mother, is particularly significant for controlling or regulating girls’ behaviours. The flip side is that such stigma may serve a protective function for girls, reducing their interest in experimenting with alcohol and/or willingness to drink alcohol when pressured by others. Nevertheless, this study did underscore how explicit or implicit pressure from boyfriends or other boys and men, may convince a girl to drink alcohol, and potentially expose herself to related risks, such as pressure or desire to have unprotected sex. Such pressures on girls have been documented in a few sub-Saharan African contexts (Birks et al., 2013; Li et al., 2010; Woolf-King & Maisto, 2011). The possibility of girl’s vulnerability did arise as well, in relation to a need or hope for financial benefit from drinking with boys and men.

Lastly, the study revealed the ways in which gendered perspectives on alcohol use in Tanzanian society may in fact represent and/or reinforce larger societal inequities. The fact that both adolescents and adults articulated girls’ (and women’s) social and biological inferiority in relation to alcohol use and by extrapolation, their ability to make decisions and ‘control’ themselves, suggests the need for more comprehensive gender norms change. Studies from other countries in the region have similarly indicated societal controls over adolescent girls’ comings and goings, with the frequent implication made that they are unable to protect themselves and thus family honour, from pregnancy or other shameful outcomes (Iliyasu et al., 2012; Izugbara, 2008; Osaki et al., 2018). However, the findings from this study seem to go further by indicating girls are in fact unable to make good decisions and/or have biologically- or chemically-based psychological weaknesses after alcohol use (in comparison to boys). The ways in which Tanzanian girls are more sheltered within society, as described above, with diminished social learning as compared to boys, may contribute to the perception that girls are socially naïve and vulnerable, or alternatively, inferior.

Importantly, an issue this study perhaps reveals is how the re-biomedicalization of the response to HIV and AIDS over the past decade, has shifted attention away from the concept of vulnerability as a focus area for social and behavioural intervention. For example, the application of Treatment-as-Prevention (TasP), Post-Exposure Prophylaxis (PEP), and Pre-Exposure Prophylaxis (PrEP) aimed at slowing the HIV epidemic all do so without having to focus as much on the issue of vulnerability within certain populations that in turn increase risk. However, more sensitive social science research on the possible determinants of HIV risk still demonstrates that there exist major social factors that can place people at increased vulnerability, both in relation to HIV and a range of other risks such as other sexually transmitted infections and pregnancy, which the provision of antiretroviral medications cannot resolve. Precisely because this is the case, understanding social vulnerability, and focusing on the social determinants of health and illness, are still very worthwhile. As vulnerability is highly ‘gendered’ almost everywhere, and certainly in sub-Saharan urban environments like Dar es Salaam in Tanzania, focusing on it has major implications for thinking about disease prevention and health promotion in such contexts among adolescents.

There are important limitations to mention about this study, including the qualitative methodology limiting the generalizability of the findings to all youth in Dar es Salaam or to other urban areas in Tanzania. However, the relatively diverse sampling conducted across the four sites in Dar es Salaam nevertheless provides a rich picture of young people’s interactions with alcohol (and unsafe sex). Similarly, the study having been conducted in an urban area limits the relevancy of the findings for rural Tanzania where the prevalence of and influences surrounding home brewed alcohol and cultural traditions around alcohol may be stronger.

Conclusions

Our findings reinforced the critical importance of capturing youths’ lived experiences through participatory methodologies in relation to an aspect of their lives, health and wellbeing, and the ways in which gender influences those realities. A number of recommendations emerge from the findings reported here, including one, the need for additional in-depth research on the gendered use of alcohol beyond urban Tanzania to rural areas, where homebrew, cultural traditions and religion may influence youth patterns of uptake and use; two, although the capturing of youth’s experiences and insights through qualitative research methods is essential, there is also a need for quantitative data on the scope of the challenge of pressure to consume alcohol for boys in particular, to guide investment in alcohol prevention and harm reduction interventions by governments and donors; and three, interventions that seek to reshape hegemonic notions of masculinity that serve to both increase boy’s vulnerability and diminish perceptions of girls’ limited capabilities within the society. The latter in particular would have relevance not only for Tanzania, but for numerous societies where masculinity continues to negatively influence boys’ and men’s lives, and through extension, those of girls and women.

List of Abbreviations

HIV

Human Immunodeficiency Virus

AIDS

Acquired Immunodeficiency Syndrome

TasP

Treatment-as-Prevention

PEP

Post-Exposure Prophylaxis

PrEP

Pre-Exposure Prophylaxis