This study investigated risk and protective factors that influence the prevalence of alcohol and drug use among secondary school students in Botswana. These results can aid the development of policies and programming designed to reduce adolescents’ high consumption of alcohol and drugs in this and similar settings. Our data suggest a number of practical solutions to target this issue.

The prevalence rates of student alcohol and drug use found by our study is significantly higher than previously reported rates in Botswana, lending quantitative support to the concerns raised by local educational professionals. Our study found that 42.1% of secondary school students reported alcohol use (defined as an AUDIT score > 0), more than twice the rate (18.9%) found among of upper primary and secondary students surveyed during the 2010 Botswana Ministry of Education (MOE) Youth Risk Behavior Surveillance Report, and the 20.5% of secondary students ages 13–15 who reported alcohol use in the past 30 days in the 2005 WHO Global School-based Student Health Survey [1, 2]. Rates of hazardous drinking also appear to be higher: Our study showed 22.5% of secondary school students had AUDIT scores indicative of hazardous drinking compared to 16.6% Batswana students ages 13–15 reporting adverse consequences from drinking alcohol in the WHO 2005 Global School-based Student Health Survey. The rate of ever having used illicit drugs (16.7%) was also higher than seen in previously reported studies [1, 2]. In the 2010 Youth Behavior Surveillance Survey Report conducted by the Botswana MOE, 13.2% of students reported marijuana use one or more times. It is unclear if the higher prevalence rate of student substance use seen in our study is due to temporal changes or geographical differences.

While little prior data existed to explain risk factors for substance use among youth in Botswana, studies from neighboring South Africa offer opportunities for comparison. A study conducted in rural South Africa, identified several community influences associated with adolescent use of home-brewed alcohol. Positive correlations existed between alcohol use and the number of adults an adolescent knew to “engage in antisocial behaviors,” such as drug use, as well as between alcohol use and an adolescent’s perception of his or her neighborhood being in a “derelict state and being unsafe.” On the other hand, a negative correlation existed between alcohol use and perceived community affirmation [26]. It has also been shown that there is a correlation between physical punishment during childhood and alcohol use later in life [27].

Within peer-reviewed literature, our findings are consistent with several other studies demonstrating the high prevalence of substance use in Botswana and Southern Africa, including among young adults and college students [28–31]. This study broadens the evidence base by specifically investigating a younger school-going adolescent population. In our study, 35.1% of Form 1 students and 40.4% of Form 2 students (equivalent to grades 8 and 9 in American schools) reported alcohol use. This finding highlights the importance of alcohol and drug use prevention interventions that target younger adolescents.

Our data suggest a number of practical solutions to target adolescents’ high consumption of alcohol and drugs in this and similar settings. Prominent risk factors for alcohol and drug use among secondary school students include opportunity risk, models risk, and vulnerability risk. Most remarkably, adolescents with easy access to alcohol, whether at home or in their community, were 3.5 times more likely to drink hazardously or use drugs (see Table 3). This finding is consistent with studies examining adult populations, which likewise found that easy availability of alcohol, including home-brewed alcohol, and its use in gatherings and community activities, contributes to alcohol abuse in Botswana [31–33]. Interventions aimed at reducing the availability of alcohol and drugs for secondary school students could include increased funding for enforcement of underage drinking laws to ensure that businesses or individuals are not selling alcohol to minors. A similar intervention had a mitigating effect on adolescent drinking in California, USA [34]. Alternatively, regulating the density of places where alcohol is both purchased and consumed may decrease alcohol availability, and thus adolescent substance use [35]. The prevalence of alcohol and drugs in students’ homes and in social gatherings would be more difficult to control, as alcohol use is a deeply embedded social norm in Botswana [33]. However, programming could be developed for parents to educate them about the risks of having alcohol available at home and ways to reduce their children’s access. While several studies positively correlate parental monitoring, disapproval of adolescent drinking, parental modeling, parent-child relationship quality, and general communication with decreased adolescent alcohol use, future studies are needed to evaluate the effectiveness of parental interventions on adolescent substance use [36–38]. For example, a recent systematic review and meta-analysis on the effects of parental alcohol rules on risky drinking pooled evidence from 13 studies conducted in the US, Sweden and the Netherlands and found that teens with parents who set rules concerning alcohol were less likely to develop risky drinking or related problems (OR = 0.64, 95% CI: 0.48, 0.86) [38]. Further studies within the Southern African context are needed to determine if interventions aimed at supporting and changing alcohol and illicit drug-related parenting are similarly protective.

Adolescents who report having family members or peers who use drugs or alcohol are considered to have models risks. Our study found that adolescents at high peer models risk were 1.7 times more likely to drink hazardously and 1.6 times more likely to use drugs. This finding concurs with studies of adolescent populations all around the world [39–44]. A recent study in neighboring Zimbabwe echoed the positive correlation between family members and friends who use cannabis and student cannabis use [45]. Programming intended for the parents of adolescents with models risks may be beneficial for the entire family. Programming would also need to target adolescents themselves, as adolescents model the behaviors of their peers; for example, students could to be taught skills to resist peer pressure or be provided with more extracurricular activities. Though the evidence base is limited, a recent review of 17 studies indicates that peer-led interventions to decrease youth substance use may be effective, and may be a way to harness greater youth engagement [46]. Further research should identify the school-based interventions that adolescents themselves believe would be most successful. Some studies conducted in the US and Europe found that school-based interventions, which focus on general psychosocial development and life skills, as opposed to interventions that aim only to increase knowledge and awareness about substances, may be effective in reducing alcohol use as well as other problematic behaviors [47–49].

Our multivariable models show that individual and social controls protection contributes to a decreased risk of alcohol and drug use (see Tables 4 and 5), although they do not completely eliminate risk. These protective factors, which include peer disapproval of substance use, school attachment, family monitoring, and religiosity, most likely help individuals develop core beliefs that protect against substance use, as well as the coping strategies they need to handle the stresses they feel at home, in their social lives, or at school. For example, individuals who reported school attachment may cope with problems by discussing them with their teachers or friends, rather than by drinking alcohol or using drugs. These findings may be helpful for designing interventions. For example, drug and alcohol programming that targets parents could also educate them about the importance of supporting their children’s success at school and being available and willing to openly discuss their children’s problems. Improvements in the counseling services provided at school might also help students learn how to better cope with these stresses.

Not surprisingly, both alcohol and drug use are more prevalent among male adolescents compared to female adolescents in our study. This is concordant with studies of older individuals in Botswana [31, 32]. Although not the focus of this study, the high rates of suicidal ideation among older female adolescents presented a concerning glimpse at a different type of risk in the female students. While the overall prevalence of suicidal ideation (19.7%) found in our study is similar to that reported in other low to mid-income countries, the prevalence of suicidal ideation among female senior secondary students was particularly high [50–53]. Our study found that 31.9% of Form 4 girls and 36.0% of the Form 5 female students endorsed serious suicidal ideation within the past 12 months, and that suicidal ideation was correlated with significant increases in drug and alcohol use. Risk and protective factors for emotional dysregulation, poor distress tolerance, depression and suicidality need to be further investigated among secondary school students in Botswana, particularly among older school-going girls.

There are a number of limitations to the results of this study that are important to recognize. First, because the study is cross-sectional, we are not able to make causal judgments based on our findings. Second, all data are self-reported in the form of surveys completed at school. While students were ensured anonymity, self-reported data presents the possibility of bias in that students may have answered what they deemed was socially desirable [54, 55]. Third, there are a number of other biological, social and environmental factors we did not measure through our survey which may have effects on student drinking and drug use, such as genetic predisposition to alcohol abuse, socioeconomic status, trauma, bullying, community disorganization, poor schooling and teacher absenteeism [11]. Our study also neglected to examine adolescent tobacco use, which is a prevalent risky behavior among secondary school students in Botswana [56].

There may also be some limitations to the generalizability of our findings. Only students of Gaborone and its peri-urban locations were surveyed. While we believe that these students are similar in many ways to those in other parts of Botswana and throughout Southern Africa, the extent to which the findings are applicable to students living in rural areas is unknown. There were in fact slight differences in how students from Gaborone versus peri-urban areas answered some questions. Substance use may also be more of a social norm in urban areas, perhaps explaining greater substance use among urban adolescents [31].

While few questions were left unanswered, internal consistency was low for questions related to a few of the constructs. In particular, the Cronbach’s alpha for the models risk construct, which included four survey questions, was 0.28. This suggests that individual items within the construct do not commonly co-exist with other items within the construct.