In the market for drugs and alcohol: characterising a risk environment in Malawi

Substance use and risky sexual behaviors among young men working at a rural roadside market in Malawi.

Jere DL, Norr KF, Bell CC, Corte C, Dancy BL, Kaponda CP, Levy JA. J Assoc Nurses AIDS Care. 2015 Jul 13. pii: S1055-3290(15)00147-8. doi: 10.1016/j.jana.2015.07.003. [Epub ahead of print]

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Abstract access [1]

Editor’s notes: There has been a global focus on how substance use and associated risk behaviours contribute to HIV acquisition. Over the last decade there has been emerging evidence to suggest that substance use is increasing in the sub-Saharan African region, which is leading people to engage in risky sexual behaviour associated with HIV transmission. Despite this, there is a continued absence of research which focuses on the causes and practices of substance use, the associated impact and the opportunities to ameliorate the associated harms. This has led to a considerable knowledge gap. This paper provides a case study which offers insights into the factors which promote and sustain the relatively heavy use of marijuana and alcohol in a rural Malawian roadside market among young male labourers.

Adopting Scribener’s ecological model framework, the authors start from the premise that there are multiple level factors (societal, neighbourhood, interpersonal and individual) which shape the behaviour of men working in these markets. Using an ethnographic approach, they provide a rich description of how these multiple levels of risk factors operate and interact to facilitate men’s substance use.

The study found that the availability and use of alcohol and marijuana within the market by young men was widespread and that this was known about and broadly tolerated by key actors and groups involved in the market. The environment of the market is characterised by an ease of opportunity to consume these substances. The environment exhibited cultural norms which appeared to promote the acceptability of this behaviour and the absence of protective mechanisms to minimise the harms. There were two novel findings in the study. The first was how the perceived benefits of alcohol and marijuana use was integrated into expectations that it would help people to gain work and then do their jobs better. The second was that participants often justified their own behaviour by illustrating that it was endorsed by Ngoni culture, predominately in the area where the market was located. As such drinking alcohol was a means to perform young masculinity. This thoughtful research provides valuable evidence to support the need for programmes to include a focus on structural changes, such as availability and regulation of substance use but also in engaging with the presumed cultural norms. These should be considered alongside a more individual orientated approach in order to design a programme that is likely to be successful in reducing the harm of these behaviours. 

Gender [4], Substance use [5]
Africa [6]
Malawi [7]
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