literature review on drug abuse among the youth in ghana

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Published: 29 February 2024

Prevalence, correlates, and reasons for substance use among adolescents aged 10–17 in Ghana: a cross-sectional convergent parallel mixed-method study

Sylvester Kyei-Gyamfi 1 ,
Frank Kyei-Arthur 2 ,
Nurudeen Alhassan 3 ,
Martin Wiredu Agyekum 4 ,
Prince Boamah Abrah 5 &
Nuworza Kugbey 2 , 6

Substance Abuse Treatment, Prevention, and Policy volume 19 , Article number: 17 ( 2024 ) Cite this article

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Substance use among adolescents poses significant risks to their health, wellbeing, and development, particularly in low- and middle-income countries, including Ghana. However, little is known about the outlets and reasons for substance use among Ghanaian adolescents. This study examined the prevalence, correlates, reasons for substance use, and outlets of these substances among adolescents aged 10–17 in Ghana.

Data were obtained from the Department of Children, Ministry of Gender, Children, and Social Protection, Ghana, which employed a cross-sectional convergent parallel mixed-methods technique to collect quantitative and qualitative data from children aged 8–17, parents or legal guardians and officials of state institutions responsible for the promotion and protection of children’s rights and wellbeing. Overall, 4144 adolescents aged 10–17 were interviewed for the quantitative data, while 92 adolescents participated in 10 focus group discussions. Descriptive statistics, Pearson’s chi-square test, and multivariable binary logistic regression were used to analyse the quantitative data, while the qualitative data was analysed thematically.

The prevalence of substance use was 12.3%. Regarding the types of substance use, alcohol (56.9%) and cigarettes (26.4%) were the most common substances. Being a male and currently working are significant risk factors, whereas being aged 10–13, and residing in the Middle- and Northern-ecological belts of Ghana are significant protective factors of substance use. Peers, household members who use substances, drug stores, and drug peddlers are the major outlets. The reasons for substance use were fun, substance as an aphrodisiac, boosting self-confidence, dealing with anxiety, and improved social status.

Conclusions

There is a relatively high substance use among adolescents in Ghana, and this calls for a multi-sectoral approach to addressing substance use by providing risk-behaviour counselling, parental control, and effective implementation of substance use laws and regulations.

Adolescence is a developmental phase associated with a greater risk of experimenting and using substances such as alcohol, cannabis and tobacco [ 1 ]. Substance use among adolescents is of major public health concern because of the short-and long-term effects on their health and safety as well as the broader negative social consequences [ 2 , 3 , 4 ]. Specifically, substance use is associated with an increased risk of road traffic accidents, violence, sexual risk-taking (such as unprotected sex), mental health disorders (including learning disorders) and suicide. While substance use among adolescents is not new in Ghana, there is evidence of the rising prevalence of some substances and the use of ‘new substances’ (such as tramadol), which have greater intoxicating effects [ 5 ]. According to Kyei-Gyamfi et al. [ 5 ], about 7% of children aged 8–17 in Ghana are lifetime users of alcohol.

In Ghana, multiple laws forbid and govern the use and sale of substances to individuals under 18. For instance, the sale of tobacco products to individuals under the age of 18 is regulated by the Tobacco Control Regulations 2016 (L. I. 2247) [ 6 ] and the Public Health Act, 2012 (Act 851) [ 7 ]. Specifically, the Public Health Act, 2012 (Act 851) forbids smoking tobacco products in public places and advertisements on tobacco products. In Ghana, anti-smoking campaigns, such as the SKY Girls campaign, employed diverse channels, including school and community activities, films, and social media, to dissuade adolescents from smoking [ 8 , 9 ]. The Food and Drugs Authority guidelines for the advertisement of foods [ 10 ] stipulate that advertisements for alcoholic beverages should not appeal to or target individuals under 18. Consequently, the Food and Drugs Authority is responsible for examining and authorising all advertisements related to alcoholic beverages. In addition, alcoholic beverage companies are prohibited from selling or providing their products as prizes for sponsorship programmes at educational institutions.

Also, the Liquor Licensing Act 1970 (Act 331) [ 11 ] regulates the sale of alcoholic beverages to individuals under 18. Act 331 also stipulates that individuals under 18 should not be permitted to enter or be found in any premises where alcoholic beverages are sold. Furthermore, the Narcotic Drugs (Control, enforcement and Sanctions) Act, 1990 (P.N.D.C.L. 236) [ 12 ] forbids the utilisation of narcotic drugs by any individual without legal authorization, including children.

While a body of research exists on substance use in Ghana, it is essential to acknowledge some limitations associated with these studies. First, these studies have mainly used a type of substance to measure substance use (e.g., alcohol use, tobacco use, and shisha use) [ 2 , 5 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. For instance, Kugbey’s [ 2 ] study measured substance use among adolescents using alcohol use, amphetamine use, and marijuana use. Similarly, Asante and Nefale [ 18 ] estimated substance use using alcohol use, cigarette use, marijuana use, glue, heroin, and amphetamine. To the best of our knowledge, no study in Ghana has used varieties of substance use as a composite variable to measure substance use. Second, most studies have focused on in-school adolescents [ 2 , 13 , 14 , 15 , 16 ]. Third, few studies have interrogated the various sources and outlets where adolescents procure substances [ 5 ]. Therefore, this study examined the prevalence, correlates and reasons for substance use as well as the outlets where such substances are procured among adolescents aged 10–17 in Ghana.

Data and sample

The study employed secondary data as the primary source of information. The data was acquired from the Department of Children within the Ministry of Gender, Children, and Social Protection in Ghana, which employed a cross-sectional convergent parallel mixed-method technique to collect quantitative and qualitative data from children aged 8–17, parents or legal guardians and officials of state institutions responsible for the promotion and protection of children rights and wellbeing. A convergent parallel mixed-method technique enables the simultaneous gathering and examination of quantitative and qualitative data [ 20 ]. The secondary data cover several topics, including children’s rights, substance use, employment, and sexual and reproductive health. This study focused on substance use.

The quantitative data in this study was obtained using a multi-stage sampling procedure to select respondents. In 2018, a sample of 20% of the total 216 districts in Ghana was chosen, with the selection criteria focusing on child welfare issues, such as child rights and child protection. As a consequence, a total of 43 districts were chosen. Furthermore, 645 enumeration areas were selected by choosing 15 enumeration areas in each of the selected 43 districts. Moreover, the study involved the selection of children between the ages of 8 and 17 residing in households within each enumeration area. In each household, it was ensured that just one child between the ages of 8 and 17 was selected for the interview. However, this study focused on adolescents aged 10–17. Overall, 4144 adolescents aged 10–17 were interviewed for the study. Figure 1 is an organisational flow of the multi-stage sampling procedure for the quantitative data collection. The inclusion criteria for children to participate in the study were: they must be aged 8–17, be a member of eligible households in selected EAs, must consent and be willing to participate, and parents/legal guardians must consent for them to participate in the study.

Multi-stage sampling procedure for the quantitative data collection

In order to gather qualitative data, ten focus group discussions (FGDs) were carried out with adolescents aged 10 to 17 years at locations convenient for them. Each FGD consisted of 8–10 participants, encompassing male and female adolescents across various age groups. Overall, 92 adolescents aged 10–17 participated in the ten FGDs. Topics covered in the FGDs included the types of substances adolescents use, where adolescents get substances to use, and the reasons for the use of substances.

The study was approved by the National Child Protection Committee of the Department of Children of the Ministry of Gender, Children, and Social Protection. Adolescents gave their written informed consent before trained research assistants interviewed them. Also, research assistants received written informed consent from parents or legal guardians of eligible adolescents before interviewing them. Experienced research assistants proficient in mixed-method data collection were enlisted and underwent a comprehensive training session on the data collection tools, as well as the objectives and significance of the study. Further information regarding the sampling process might be obtained in prior studies [ 21 ].

Study variables

Dependent variable.

Substance use was the dependent variable for this study. It was a composite variable computed using two questions, “Have you ever taken alcohol?” and “Have you ever taken drugs?”. Respondents who responded “Yes” to either or both questions were classified as engaging in substance use.

Independent variables

The independent variables were sex (Male and Female), age (10–13 and 14–17), education (Less than Junior High School (JHS), JHS, and Senior High School (SHS) and higher), marital status (married and not married), religion (Christianity, Islam, and Other), and currently doing any paid work (Yes and No). The region of residence of respondents was recoded into three (3) ecological belts: Coastal ecological belt (Western, Central, Greater Accra, and Volta regions), Middle ecological belt (Eastern, Ashanti and Brong Ahafo regions), and Northern (Northern, Upper East and Upper West regions) ecological belt.

Statistical analyses

The Statistical Package for the Social Sciences (SPSS) version 26 was used to perform the statistical analyses for the quantitative data. Descriptive statistics was used to describe the socio-demographic characteristics of respondents and the types of substances respondents use. Pearson’s chi-square test was used to examine the association between substance use and socio-demographic characteristics of respondents. A multivariable binary logistic regression was performed to examine the correlates of substance use. All variables in the quantitative data were determined to be statistically significant at p-value ≤ 0.05.

QSR NVivo version 10 software was used to analyse the qualitative data thematically. The researchers examined all transcripts to gain insights into respondents’ viewpoints regarding substance use among adolescents. Subsequently, the transcripts were thoroughly examined, and utterances pertaining to the substance usage of the adolescents were systematically categorised using codes. Sub-themes were identified from the identification and grouping of similar codes found within the transcripts. Moreover, the process involved clustering comparable sub-themes to generate overarching themes.

Socio-demographic characteristics of respondents

The socio-demographic characteristics of respondents are displayed in Table 1 . A little more than half of the respondents (50.7%) were males, while most were Christians (76.4%). Most respondents were unmarried (98.9%) and currently not engaged in any paid work (95.2%). Among those currently working, a higher proportion were males (68.3%) than females (31.7%) (See Table S1 in the supplementary material).

More than half of respondents (53.0) were aged 15–17. Also, 3 out of 10 respondents (30.5%) had attained less than JHS education, and about two-fifths (39.6%) resided in the Middle ecological belt.

Prevalence of substance use

The prevalence of substance use was 12.3% (95% CI = 11.34 − 13.37%) (Table 1 ). In terms of sex, a greater proportion of males (15.8%) engaged in substance use than females (8.8%, p ≤ 0.001). More respondents aged 15–17 (18.1%) engaged in substance use than those aged 10–13 (5.9%, p ≤ 0.001). It can be observed that respondents’ education was positively associated with the prevalence of substance use ( p ≤ 0.001). Most respondents with SHS and higher education (19.2%) engaged in substance use, followed by those with JHS (12.0%) and less than JHS (5.7%) education. Also, most respondents who resided in the Coastal ecological belt (16.6%, p ≤ 0.001) and those who are currently doing paid work (28.1%, p ≤ 0.001) engaged in substance use.

Regarding the type of substance respondents use, alcohol (56.9%) and cigarettes (26.4%) were the most common substances (Table 2 ). About 7% of respondents (6.5%) used tramadol, and 4.8% used marijuana. Other substances respondents used include codeine (1.7%), cocaine (1.5%), shisha (1.2%), and heroin (1.0%).

Generally, more male adolescents used all types of substances than female adolescents. For instance, of those adolescents who used codeine, 90% were male, and of those who used tramadol, 86.8% were male. Similarly, older adolescents (14–17 years) generally used all types of substances than younger adolescents (10–13 years), except heroin. For instance, about 9 out of 10 older adolescents (89.5%) used tramadol, while 88.3% used cigarettes. However, more younger adolescents (66.7%) used heroin than older adolescents (33.3%).

Correlates of substance use

From Table 3 , males (AOR = 2.117, 95% C.I. = 1.731–2.589, p ≤ 0.001) and respondents who are currently working (AOR = 1.821, 95% C.I. = 1.295–2.560, p = 0.001) were more likely to engage in substance use. However, respondents aged 10–13 (AOR = 0.333, 95% C.I. = 0.232–0.478, p ≤ 0.001) and residing in the Middle (AOR = 0.510, 95% C.I. = 0.409–0.636, p ≤ 0.001) and Northern (AOR = 0.597, 95% C.I. = 0.451–0.790, p ≤ 0.001) ecological belts were less likely to engage in substance use.

Where respondents get substance

During the FGD with respondents, issues were discussed regarding where children get their substance. Four themes emerged: (a) supplies from their peers, (b) household members who also use substances, (c) purchasing from drug stores, and (d) purchasing from drug peddlers.

(A) supplies from peers

Respondents explained that friends with connections can provide access to illicit substances. They explained that most adolescents who engage in substance use are extremely cautious when searching for their drug of choice, as they are aware that the simplest act of irresponsibility will get them in trouble. As a result, they rely on their peers who also engage in substance use since they can trust them.

Most drug-using young people only associate with peers who also use drugs. Through this, they can establish a network, gain each other’s trust, and obtain supplies, as suppliers find it convenient to give substances to trustworthy individuals. Once a member obtains supplies, they may distribute them within their respective circles. (FGD 1)

(B) household members who use substances

Household members who engage in substance use also serve as suppliers of substances. It was found that some adolescents obtain substances from their siblings, uncles, and other household members who also use substances. One participant explained this phenomenon:

”My first taste of whisky came from my older brother’s room. Since I frequently observe him drinking before meals, I decided to try it one day, and it has since become my primary source of alcohol. Some of my smoking acquaintances obtain their supplies from their brothers, too. (FGD 2)”.

(C) purchasing from drug stores

The FGDs with adolescents revealed that some adolescents acquire tramadol from small medicinal retail outlets known as ‘drug stores’. Adolescents explained that acquiring such medications from a pharmacy is risky due to the possibility of being tracked down for drug use. A participant explained:

When customers enter small drugstores in densely populated communities, they are rarely asked what they intend to use the medication for. Not so with pharmacies, which are well-established and staffed by licenced pharmacists. Due to this, some adolescents purchase codeine and tramadol from them to avoid getting caught. (FGD 3)

(D) purchasing from gangs

Adolescents’ narratives highlighted that they purchase substances from gangs, who often get their supplies from drug peddlers. However, the gangs only sell to individuals they know and can vouch that they may not expose them to the police. Adolescents explained that one must be known to be a reliable client before buying from a gang. These gangs are not at specific locations but operate in areas noted for substance use.

Drug peddlers who occasionally offer marijuana do not sell to adolescents. Typically, an adult member of a gang buys it and distributes it around the groups, usually on the basis that he receives a free supply, while adolescents or underage members provide monies for the purchase of the marijuana. (FGD 4)

Reasons for substance use

Adolescents narrated varied reasons for using substances. Five themes emerged: (a) substance use is fun, (b) use of substances as an aphrodisiac, (c) boosts confidence to approach the opposite sex, (d) forgetting anxieties, and (e) substance use makes one popular and being perceived as the finest.

(A) substance use is fun

For some adolescents, substance use is fun. Occasionally, meeting friends, drinking, and smoking add spice to the entertainment of adolescents. One of the adolescents described how he has enjoyed drinking with his neighbourhood friends over the years:

The greatest time of my life is when my friends and I assemble at drinking places [pubs], listen to music, dance to some songs, consume alcohol, smoke, and party. Life is great when unwinding with friends. (FGD 5)

(B) use of substances as an aphrodisiac

During the FGD, it emerged that the use of tramadol, also known as ‘Tramol’, has become widespread among many adolescents in the country’s urban communities since it serves as an aphrodisiac, which enhances their sexual performance. One adolescent stated:

Boys who use Tramol in my area claim that it allows them to have long-lasting sexual intercourse with their partners whenever they have sex. As a result, many adolescents use Tramol as an aphrodisiac. (FGD 6)

(C) boosts confidence to approach the opposite sex

Some adolescents believe that when they use substances, it boosts their confidence to approach the opposite sex. They use substances to overcome their shyness to approach the opposite sex. Below is the narrative of a respondent:

Some of the boys drink alcohol or even smoke marijuana because they may lack the confidence to approach a girl they are interested in. However, they firmly believe that by using drugs, they will become high and be better positioned to accomplish their goal of flirting with the girls. (FGD 7)

(D) forgetting anxieties

The FGD with adolescents revealed that some adolescents use substances to help them forget about their anxieties about the lack of employment opportunities, educational opportunities, and other family issues. One participant explained why he has been drinking:

I finished Polytechnic and have been home for two years without a job. Most of my peers are in similar situations, so when we get together, those of us with money purchase drinks and split them amongst ourselves so we can commiserate and console ourselves about our jobless situations. (FGD 8)

(E) substance use makes one popular and being perceived as the finest

Adolescents revealed that some adolescents have the misconception that engaging in substance use makes them popular and perceived as the ‘finest’ [best] in their peer group. The following were the sentiments expressed:

Most children who smoke cigarettes and marijuana believe they become popular with their peers and are highly regarded as the finest guys in their group when they smoke. Many boys and girls of my age group are influenced to indulge in substance use due to the widespread prevalence of these misconceptions. (FGD 9)

Although there have been many studies conducted on substance use in Ghana, only a limited number of these studies have utilised multiple types of substances to assess substance use. Moreover, most of these studies have concentrated on adolescents attending school. At the same time, only a limited number of studies have examined the diverse channels and locations through which adolescents obtain substances. To close this disparity in knowledge, this study examined the prevalence, correlates and reasons for substance use as well as the outlets where such substances are procured among adolescents aged 10–17 in Ghana. The findings of this study would contribute to the literature on substance use, and it would help to inform policymakers in providing programmatic responses to address substance use among adolescents, which has long-term health implications for their lives.

We found that the prevalence of substance use among adolescents was 12.3%. The prevalence of substance use in this study is higher than that of 6.6% found in 7.2% in Uganda [ 22 ] and 11.3% in sub-Saharan Africa [ 2 ]. In contrast, the prevalence of substance use in this study is lower than 16.0% in India [ 23 ], 17.1% in Southern Brazil [ 24 ], 32.9% in Nigeria [ 25 ], and 48% in South Africa [ 26 ]. A study in Northern Tanzania reported a lifetime and current prevalence of substance use of 19.7% and 12.8%, respectively [ 27 ]. The variation in the prevalence of this study and other studies could be attributed to the sample size of adolescents, socio-cultural factors, demographic characteristics, age of adolescents and the types of substance use that were considered in each study. For instance, Mavura et al. [ 27 ] considered alcohol, cigarette smoking, marijuana, khat, and recreational drugs (cocaine, heroin) in their study, while in this study, we considered alcohol, smoking and drugs (Marijuana, heroin, cocaine, codeine and tramadol). In addition, the differences in the age of adolescents could account for the variations in the prevalence of substance use among adolescents. In this study, we considered adolescents aged 10–17. However, Kugbey’s [ 2 ] study participants were aged 11–18, while Mmereki et al.’s [ 26 ] study participants were aged 13–21.

The results of this study show that alcohol was the most common substance used among adolescents, followed by smoking (cigarettes), tramadol, marijuana, codeine, cocaine, shisha and heroine. The findings of this study are similar to a study by Mavura et al. [ 27 ], who reported alcohol as the common substance use by adolescents in Tanzania. Similar findings were found by Anyanwu et al. [ 25 ] in Nigeria, Birhanu et al. [ 28 ] in Northwest Ethiopia, and Olawole-Isaac et al. [ 29 ] in Sub-Saharan Africa. The probable reason for the high prevalence of alcohol use may be attributed to the visibility and advertisement of alcohol in Ghana, which may entice adolescents to drink. Akesse-Brempong and Cudjoe [ 30 ] argued that there is a pervasive and robust advertising campaign promoting the consumption of alcoholic beverages in Ghana, which has the potential to influence adolescents to consume alcohol. Aside from the advertisement, there are more drinking spots where adolescents can easily access any alcoholic beverage. Hormenu et al. [ 14 ] reported that in Ghana, about 42.3% of adolescents have ever consumed alcohol. It is, therefore, not surprising that alcohol was the major substance used by adolescents in this study. In addition, studies have identified smoking cigarettes as the second substance adolescents use [ 25 , 27 , 28 ]. In contrast, Srivastava et al. [ 23 ] found the use of tobacco to be higher in India than alcohol.

The findings of the study show that males were more likely to engage in substance use than females, similar to other studies [ 2 , 5 , 28 , 31 ]. The higher use of substances among males may be attributed to gender roles, peer influence and sensation-seeking behaviour, which sometimes forces males to use substances to enable them to behave as they desire [ 28 ]. Iwamoto et al. [ 32 ] reported that substance use, such as alcohol and drugs, shows masculinity, whereas men who do not take alcohol or drugs are considered weak. Men conform to these masculine norms or beliefs, such as “playboy” and “risk-taking and self-reliance”, which increase their risk of substance use. In contrast, engaging in substance use among females is sometimes seen as shameful, and society frowns on it [ 2 ]. Due to this, there could be a situation of underreporting of substance use among adolescent females.

The study results show that adolescents aged 10–13 years were less likely to engage in substance use than those aged 14–17 years. The finding of this study is similar to other studies that reported substance use practice among older adolescents than younger adolescents [ 25 , 26 ]. The probable reason could be that as adolescents grow, they begin to live independent lives by making their own decisions, and this sometimes leads them to engage in unhealthy lifestyles such as drinking alcohol and taking drugs. Older adolescents become susceptible to experimentation with different things, such as drugs and alcohol. Sometimes, this is done out of curiosity or peer pressure from friends as they age [ 25 , 33 ]. However, older adolescents may lack the knowledge and consequences of using these substances, and their continuous use may lead to addiction.

In addition, we found that adolescents who were currently working were more likely to engage in substance use than those who were not working. Adolescents who are working may have the financial resources to purchase substances to use than those who are not working. This finding is similar to previous studies, which found that respondents who were working as vulnerable groups that engaged in substance use [ 23 , 34 , 35 ]. However, this finding is contrary to Masferrer et al. [ 36 ] study, which found substance use is more likely among respondents who are not working.

Furthermore, adolescents residing in the Coastal ecological belt are more likely to engage in substance use than those living in the Middle and Northern ecological belts. Previous studies have found the use of alcohol among persons residing in Coastal areas in Ghana [ 37 ]. Also, the use of tramadol has been documented to be more prevalent in the Greater Accra, Volta, and Western regions, which are found in the Coastal ecological belt [ 38 ]. Kyei-Gyamfi and Kyei-Arthur’s [ 19 ] study on substance smoking in Ghana found cigarette smoking to be more prevalent in the Coastal ecological belt than in the Middle and Northern belts of Ghana. These factors may explain why adolescents living in the Coastal ecological belt are more likely to use substances than those in the Middle and Northern ecological belts.

Consistent with other studies [ 39 , 40 ], the findings of this study revealed various reasons for substance use, such as for fun, as an aphrodisiac, to boost confidence to approach the opposite sex, forgetting anxieties, making one popular and being perceived as the finest. The probable reason for this could be that most adolescents are sometimes shy of approaching the opposite sex. Therefore, they use substances to boost their confidence to approach them. In addition, due to youthful exuberances, adolescents are involved in risky sexual behaviour and, therefore, use various substances as aphrodisiacs to please their partners during sex [ 41 ]. In Ghana, Attila et al. [ 42 ] reported that substance use among adolescents is due to curiosity, which is similar to the findings of this study.

The study found that adolescents obtained their substances from peers, household members who engage in substance use, drug stress and gangs. Similar findings of this study have been reported by other studies [ 43 , 44 ]. For instance, Lopez-Mayan & Nicodemo [ 43 ] reported that peers significantly influence adolescent substance use in Spain. These adolescents get the substances from their peers in schools, thereby impacting their use. Schuler et al.’s [ 44 ] study in Southern California reported that adolescents acquire the substance they use from their friends and family members. Similarly, Srivastava et al.’s [ 23 ] study in India found that the probability of an adolescent engaging in substance use is heightened when they have a family member who also engages in substance use. Thus, peers and family members who use substances may influence adolescents to also use substances.

Limitations

There are some limitations to this study. First, substance use was defined as the lifetime use of a substance, and it was measured by a single question, which was not a robust measure of substance use. Second, children were asked if they had ever used substances. Since substance use is regarded as a deviant behaviour and unlawful, children might fail to disclose their use. Third, there may also be recall bias because children must recollect when they used a substance, which may lead to under reporting of their experiences. Fourth, because this is a cross-sectional study, we are unable to establish causal links between the dependent and independent variables. Despite these limitations, the data’s national representativeness would allow policymakers and researchers to tackle substance use among adolescents across the country.

This study revealed a relatively high prevalence of substance use (12.3%) among adolescents, and alcohol and cigarettes were the main substances used by adolescents. Adolescents obtain the substances they consume from their peers and household members who are substance users, as well as from drug stores and drug peddlers. The study highlighted adolescent’s age, sex, ecological zone of residence and working status as significant correlates of substance use.

Furthermore, it emerged that adolescents use substances because they want to boost their self-confidence to approach the opposite sex, forget their anxieties, and it served as a form of aphrodisiac. Other adolescents use substances since they perceive them as fun, and the use of substances makes their peers perceive them as famous.

Though the study found that only a little over one-tenth of adolescents (12.3%) used substances, substance use is detrimental to the health and wellbeing of adolescents. Consequently, there is a need for muti-sectoral collaborations between institutions mandated to enhance the wellbeing of adolescents and implement substance use laws and regulations, such as the Narcotic Control Authority, the Ministry of Gender, Children, and Social Protection, and other child protection partners, to help reduce adolescent substance use. Also, there is a need to provide risk-behaviour counselling to adolescents and to strengthen parent control to help curb adolescent substance use in Ghana.

Data availability

The raw data for the findings of this study are freely available from the corresponding author upon request.

Abbreviations

Adjusted Odds Ratio

Confidence Interval

Focus Group Discussions

Junior High School

Ministry of Gender, Children and Social Protection

Reference Category

Senior High School

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We thank all respondents who made this study possible and the Department of Children, Ministry of Gender, Children and Social Protection for granting us access to this dataset.

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Kyei-Gyamfi, S., Kyei-Arthur, F., Alhassan, N. et al. Prevalence, correlates, and reasons for substance use among adolescents aged 10–17 in Ghana: a cross-sectional convergent parallel mixed-method study. Subst Abuse Treat Prev Policy 19 , 17 (2024). https://doi.org/10.1186/s13011-024-00600-2

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Where is the pain? A qualitative analysis of Ghana’s opioid (tramadol) ‘crisis’ and youth perspectives

Roles Conceptualization, Writing – original draft

* E-mail: [email protected]

Affiliations Ad Astra Foundation, Tamale, Ghana, Oxford School of Global and Area Studies, University of Oxford, Oxford, United Kingdom, Department of Community Health & Epidemiology, University of Saskatchewan, Saskatoon, Canada

Jacob Albin Korem Alhassan

Published: December 21, 2022
https://doi.org/10.1371/journal.pgph.0001045
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Over the last five years, media reports in West African countries have suggested a tramadol abuse ‘crisis’ characterised by a precipitous rise in use by youth in the region. This discourse is connected to evidence of an emerging global opioid crisis. While the reported increase in tramadol abuse in West Africa is likely true, few studies have critically interrogated structural explanations for tramadol use by youth. Nascent academic literature has sought to explain the rise in drug use as a function of moral weakness among youth. This Ghanaian case study draws on primary and secondary data sources to explore the pain that precedes tramadol abuse. Through a discourse analysis of 295 media articles and 15 interviews (11 with youth who currently use tramadol and 4 with health system stakeholders), this study draws on structural violence and moral panic theories to contribute to the emerging literature on tramadol (ab)use in West Africa. The evidence parsed from multiple sources reveals that government responses to tramadol abuse among Ghanaian youth have focused on arrests and victim blaming often informed by a moralising discourse. Interviews with those who use tramadol on their lived experiences reveal however that although some youth use the opioid for pleasure, many use tramadol for reasons related to work and feelings of dislocation. A more complex way to understand tramadol use among young people in Ghana is to explore the pain that leads to consumption. Two kinds of pain; physical (related to strenuous work) and non-physical (related to anxiety and the condition of youth itself) explain tramadol use requiring a harm reduction and social determinants of health approach rather than the moralising ‘war on drugs’ approach that has been favoured by policy makers.

Citation: Alhassan JAK (2022) Where is the pain? A qualitative analysis of Ghana’s opioid (tramadol) ‘crisis’ and youth perspectives. PLOS Glob Public Health 2(12): e0001045. https://doi.org/10.1371/journal.pgph.0001045

Editor: Khameer Kidia, Brigham and Women’s Hospital, UNITED STATES

Received: March 6, 2022; Accepted: November 25, 2022; Published: December 21, 2022

Copyright: © 2022 Jacob Albin Korem Alhassan. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Excerpts of the transcripts relevant to the study are available within the paper. Anonymized transcripts are not publicly available due to ethical and legal reasons (participants discuss their use of illicit drugs). The author can make raw data/transcripts available upon request and as appropriate.

Funding: The author received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

“It is important we let people know that abusing medicines like tramadol can have bad consequences including death” [ 1 ]. These words by the Chief Executive Officer (CEO) of Ghana’s Food & Drugs Authority (FDA) were published in an article on 5 May 2018 on GhanaWeb , one of Ghana’s main online news outlets. Although a couple of years prior most newspaper articles did not routinely mention tramadol or its popularly contracted form “tramol” in their reportage (see Fig 1 ), by 2018 it had become common to see newspaper publications and radio and television programs dedicated to helping solve the tramadol ‘crisis’. In the ensuing months international news outlets such as Deutsche Welle all pointed to a rising trend in the consumption of “cheap and accessible” opioids by Ghanaian and West African youth [ 2 ]. While the current West African situation was linked to tramadol, it must be understood in the context of more complex histories of drug use in Africa [ 3 ] and a rise in opioid use globally driven by multiple factors ranging from “aggressive marketing” [ 4 ] by pharmaceutical industries to changing criminal networks connecting and distributing drugs across continents [ 5 ]. The opioid crisis is increasingly recognised as a global health issue particularly in North American and European contexts where pharmaceutical companies are beginning to be held accountable for decades of over-prescribing opioids while understating the dangers of opioid use [ 6 ].

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Reports of precipitous increases in drug use have become common across several African countries for different drugs. In the context of the COVID-19 pandemic for example, associated joblessness has led to a rise in drug use in countries such as Zimbabwe where more youth use crystal meth [ 7 ], while recent research evidence from South Africa illustrates increasing heroin use among the young male labouring poor, many of whom have precarious employment and use heroin as a coping mechanism [ 8 ].

This article is situated in the broader context of drug use in Africa, discourses of a dangerous and precipitous rise in drug use, especially among youth, and questions on how to explain this issue. In this article, I explore the reported rise in tramadol consumption and use in Ghana and media portrayal of this phenomenon over the last five years. I argue that the framing of the tramadol ‘crisis’ was a moral panic and that such framings helped justify the solutions the government and key stakeholders have adopted to respond to its use—namely, public education and arrests while ignoring root causes of drug use such as poor economic prospects. Relying on the lived experiences of Ghanaian youth who use tramadol, I draw on rich local descriptions to offer a different way of thinking about these youth, as many are simply young people striving to survive in an economy where their situations are highly precarious.

Drawing on key themes in Africanist scholarship, I contribute to this nascent literature by critically (re)interpreting the rise in tramadol use in Ghana in the context of youth and waithood. I argue that its use needs to be understood in the context of the physically demanding and precarious employment conditions many young Ghanaians face, their anxiety and uncertainty regarding their prospects and the demanding conditions of work with which many of them must contend.

Finally, I argue that a better way to understand tramadol use among young people in Ghana is to explore the pain that leads to consumption while moving away from the moralising discourses that have been the core approach of the government and other stakeholders. By paying particular attention to pain and themes of youth—and through a proposed framework—I show that tramadol is used as a coping mechanism for many young people who are struggling to find their place in the context of perpetual waithood and global neoliberal processes that shape young people’s lives [ 9 ]. The reality of tramadol use requires improvement of young people’s economic prospects and strengthening of mental health systems rather than victim blaming.

1.1 Tramadol in Ghana

Tramadol is a pharmaceutical drug with weak μ-opioid agonist properties, whose M1 metabolite is the primary mechanism for its analgesic (pain killer) effect [ 10 ]. The drug was originally distributed by the German pharmaceutical company Grünenthal in 1977. It was historically used to treat pain in situations where paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase (Cox)-II inhibitors were insufficient or in patients without tolerance to these alternatives [ 11 ]. It is the only opioid not under international drug control. Multiple meetings (four between 1992 and 2006) by the World Health Organisation Expert Committee on Drug Dependence (ECDD) concluded that tramadol has low abuse potential especially among those with no history of substance use although research from China showed some evidence of abuse potential [ 12 ].

The emerging academic literature on tramadol in Ghana falls into two main categories. (There is a third emerging literature on the role of the media in the tramadol ‘crisis’; see Thompson and Ofori-Parku) [ 13 ].

First, there is a developing body of epidemiological literature describing patterns of tramadol use. In a study by Elliason and colleagues [ 14 ] in the Wassa Amenfi West Municipality in the Western Region, consumption patterns were compared by socio-demographic characteristics. Among those sampled the study found that 45% of those who consume tramadol were male and 49% were aged 16–30. One of the most interesting findings from the study which did not receive much analytical attention was the fact that only two per cent (2%) of those who consume tramadol worked in the ‘formal sector.’ Saapiire et al. [ 15 ] based on research in Jirapa in northern Ghana also recently reported a high prevalence of tramadol abuse especially among males (90.7%) compared to females (9.3%) and concluded that formal sector employment is “protective against tramadol abuse.” Given the high percentage of usage among young men working in the informal sector, it would be useful to explore why this demographic uses tramadol more and the ways the context of work may be implicated.

The second body of published academic literature on tramadol has been qualitative studies exploring facilitators and motivations for use. The qualitative literature describes some of the context of this use and primarily focuses on motivations for use and effects of tramadol on users. Fuseini et al. [ 16 ] concluded for example that peer pressure, curiosity and post-traumatic addiction are the main initiating factors for tramadol use. This study also argued that effects of consumption can be desirable (analgesic psychological effects and even aphrodisiac effects) or undesirable (vomiting and seizures or irritability and aloofness) [ 16 ]. Finally, in a qualitative study in Kumasi, Peprah and colleagues [ 17 ] also drew similar conclusions regarding the drivers of tramadol consumption, arguing that people use it because of sexual, psychological and physical motivations.

There are some gaps in the emerging tramadol literature and opportunities for further research. First, most of the literature focuses on the effects of consumption rather than structural causes of tramadol use. Additionally, academic publications on effects of tramadol use have highlighted key challenges including suicide ideation [ 18 ] although almost no overdoses have been reported from Ghana unlike has been the case with opioid crises elsewhere [ 4 ]. The absence of academic reports on overdoses could be because of the lower potency of tramadol although it could also be a function of data unavailability in the African context [ 19 ]. In countries such as the Islamic Republic of Iran for example, overdose rates from tramadol are high and a common cause of poisoning admissions to emergency departments [ 19 ]. Given these dynamics, as the tramadol situation continues to evolve in Ghana, there might be potential lessons for other contexts where stigma related to opioid use has been connected to high overdose rates. Moreover, although extant studies have described the demographic characteristics of tramadol users and highlighted high usage among men, informal sector workers and youth, they have done so mainly through descriptive statistics. This necessitates more research on the lived experience of youth who use tramadol. Finally, there is an emerging interest in harm reduction in Ghana -in the form of needle exchange programs, HIV and hepatitis B & C prevention strategies [ 20 ]—as has been advocated for in Europe and North America. The fact that tramadol is predominantly orally ingested means that new approaches to harm reduction will need to be envisioned drawing on the lived experiences of those who use tramadol.

Drug use is always influenced by a complex set of factors including “productivity, pleasure and intimacy” [ 21 ] thus a biopsychosocial understanding demands a delicate balancing of the deeper structural factors that construct the world inhabited by those who use drugs with their complex lived experiences [ 22 ]. This study turns the analytical gaze toward pain . Such attention reveals the broader causes of tramadol use because attention to and analysis of pain reveals “how the bodily experience itself is influenced by meanings, relationships, and institutions” [ 23 ].

2. Theoretical orientations

This article draws on multiple theories to problematise ongoing framings of tramadol use. First, it draws on the notion of a ‘moral panic’, a state that occurs when “a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” [ 24 ]. As applied to youth in Africa, the notion of moral panic is of particular importance given the historical and ongoing representation of African youth as “unruly, destructive and dangerous forces needing containment” [ 25 ]. In practical terms, throughout the article and in analyses, references to tramadol use by youth as “immoral” or a “crisis” are treated with some scepticism while assuming that particular framings of young people as irresponsible drug users can be used by those in power to deflect attention from root causes of drug use [ 26 ].

Secondly, the article draws on anthropological theories of structural violence and the idea of the social determinants of health. The concept of ’structural violence’ was first used by Galtung [ 27 ] to differentiate violence that is direct or interpersonal from violence that is built into social structures. Galtung’s original article was in the field of Peace Studies, however this idea has subsequently been used by authors across disciplines to explore how social structures reduce people’s life chances. For medical anthropologist Paul Farmer [ 28 ], structural violence is “violence exerted systematically” and to study this is to explore the “social machinery of oppression.” Understanding health issues such as addiction therefore requires attention to the ‘pathologies of power,’ the structures that force people to engage in health-destructive behaviours [ 29 ]. Many researchers have used this approach to understand the health of marginalised groups such as Latino migrant workers in the USA [ 30 ] or the drug economy in deindustrialised urban contexts [ 31 ]. I reinterpret tramadol use by Ghanaian youth in the context of the broader social structures of oppression in which they live and work. I draw as well on the idea of the social determinants of health [ 32 ] which posits that health behaviours are influenced by social structures. Thus, where problematic drug use emerges in the analysis, I emphasise the importance of harm reduction principles and addressing the living conditions of youth as an essential step in improving the lives of those who use tramadol.

3. Methods of the study

Ethics statement.

This study received ethics approval from the University of Oxford Social Sciences and Humanities Interdivisional Ethics Committee (SSH_OSGA_ASC_C1_21_030). The study also received an ethics exemption under the Ghana Health Services Ethics Review Committee Standard Operating Procedures 2015 given that it involved interviews with voluntary participants who gave informed consent. Informed consent was obtained from participants verbally and recorded before each interview. Three affirmations were used to secure informed consent. Each participant confirmed (1) that their participation in the research was voluntary, (2) that they give their verbal consent to participate, and (3) that a voice recorder could be used to record responses. The 11 participants received a $10 honorarium each.

Study design

This study is part of a broader research project to understand the drivers of tramadol use among West African youth. I report here mainly on the newspaper sources with some references to interview data although a longer discussion of lived experiences of youth who use tramadol is reported elsewhere [ 33 ]. The research employed a qualitative case study methodology [ 34 ] drawing on multiple methods and relying on primary and secondary data sources. The secondary data analysis involved a discourse analysis [ 35 ] of media reportage on tramadol use in Ghana between 2012 and 2020. In total, 295 newspaper articles were systematically extracted from newspaper search site Factiva , imported into NVivo 12 software, and inductively coded to describe discourses on tramadol consumption (see Fig 1 . for trends in reportage and S1 Table for codes). To conduct the discourse analysis, each article was read in its entirety and coded for: 1) how it described those who use tramadol; 2) explanations offered for tramadol use; 3) descriptions of the effects of tramadol use; and 4) how each article framed the solution to the problem of tramadol use. Once this process was completed codes were combined to explore patterns and to describe the dominant frames used in writing about the tramadol crisis [ 35 ].

Additionally, primary qualitative interviews (lasting between 30 min. and 1 h 15 min.) were conducted with fifteen (15) individuals between March and May 2021 via telephone due to the COVID-19 pandemic. Interviews were transcribed verbatim and imported into NVivo 12 software. The final sample of 15 participants was considered appropriate based on emerging analysis that revealed similar responses across interviews (approaching saturation) and the unpredictable pandemic context where interview data collection could only be performed at a distance. Recruitment was done through purposive sampling after a research poster was circulated on social media. Other participants were recruited through personal contacts given the sensitive nature of the research topic. Interviewees consisted of eleven (11) people (ten males and one female) who were currently using tramadol and worked in diverse professions (tricycle riders, self-identified ‘hustlers’, students, teachers, masons etc.). For these 11 participants the criteria for inclusion was that they be youth (age 15–35) who used tramadol [ 36 ]. Interviewees included in this analysis were aged 19–35 and had used tramadol over the last year. Interviews were conducted in English, Dagbani and pidgin English using a semi-structured interview guide. Interviewees were asked to provide a short life history, describe what led them to tramadol use, highlight socioeconomic factors that explain why they use tramadol and describe societal views of those who use tramadol. They were also asked to comment on any available supports if they wanted to stop using tramadol and finally, they were asked to share their hopes for the future ( S1 Text ).

The four other interviews were conducted with stakeholders (a journalist, a mental health nurse, a program manager and a divisional head of one of Ghana’s drug regulatory bodies) who had worked on tackling the problem of tramadol use. These stakeholders were also purposively recruited through a research poster on social media and via personal contacts to better understand Ghana’s policy response to tramadol use. The stakeholders had played keys role in the response to tramadol use in Ghana and provided high-level explanations of how they as individuals and members of institutions understood the problem and the solutions they were advocating to respond to the ‘crisis’.

Participants were recruited across cities (Accra, Tamale, Kumasi and Winneba). Illustrative quotes are labelled according to the location and sequence of interviews: T1-T4 designate Tamale-based interviews; K1-K4 (Kumasi); A1 (Accra), W1-W2 (Winneba), HCP1-3 (Healthcare Professionals), BJ (Broadcast Journalist).

To complete interview data analysis all transcripts were imported into NVivo 12 software and analysed using the six-step process described by Braun and Clark [ 37 ]. This involved: 1) familiarisation—transcripts were read and re-read; 2) generating initial codes—interesting features of each transcript were coded systematically in NVivo; 3) searching for themes—codes were combined into categories and collated into potential themes; 4) reviewing themes—emerging themes were compared to coded extracts; 5) defining and naming themes—themes that told the overall story of the analysis were refined; and 6) producing the report—themes were written up. Emerging findings were discussed with four participants who provided feedback. Research findings are reported drawing on COREQ guidelines ( S1 Checklist ) [ 38 ].

Reflexivity

I approached this study from a critical ontological perspective as a PhD trained health researcher with about 5 years of experience with qualitative methodology. My methodological choices were guided by a commitment to reveal the role of power in shaping vulnerability. I drew on my Ghanaian identity to build ethical and respectful relationships with participants. I recognise that my positionality shapes my framing of the research project and endeavoured during interviews to avoid the use of jargon and to meet participants at a level of equality. I spoke in pidgin and my local language (Dagbani) where necessary and adhered to key principles of relational ethics in working with interviewees who used tramadol.

4. Findings and discussion

It is not entirely clear what caused a major spike in media reportage on tramadol use in 2018 as shown in Fig 1 . The first Ghanaian newspaper reports on tramadol emerged from publications about drug seizures in 2012 in Nigeria. One such article noted that truckloads of drugs intercepted in some ports in West Africa had claimed to be from Ghana as part of the Economic Community of West African States’ (ECOWAS) trade liberalisation scheme but “actually originated from China” [ 39 ]. By 2015 several newspapers were regularly publishing articles on tramadol. Some of these articles focused on contracts awarded to companies to provide drugs for the health sector. From this period onwards news reports emerged regularly on tramadol and were often about criminals arrested with tramadol in their possession. The trend continued for a few months and by March 2018, Ghana’s minister of health issued warnings on the dangers of tramadol use. The sections that follow describe how tramadol use was explained and represented by the media vis à vis theoretical literature on youth.

4.1 The condition of ‘youth’ and youth futures

In analysing media sources to understand how stories are framed, one of the most salient characteristics of tramadol stories has been their connection to youth. The seventh most common word found in newspaper stories was ‘youth’, used 539 times although never clearly defined. That notwithstanding, youth—however defined—remains an important category for theoretical reasons and requires particular attention since participants themselves often invoked ideas of youth in explaining why they used tramadol.

The concept of youth, although sometimes used as a biological signifier to refer to people within the age bracket of 18–25 [ 40 ], is a complex sociological category and subject to manipulation. As Bourdieu [ 41 ] argued, across societies definitions of youth are subject to power dynamics and “the frontier between youth and age is something that is fought over in all societies.” This is particularly the case since the concept of youth and its connotations can be manipulated as a means of scapegoating and apportioning blame.

There are several reasons youth is a fertile ground for the study of health in Africa. First, youth are “particularly sensitive to transformations in the economy as their activities, prospects and ambitions are dislocated and redirected” [ 25 ]. In this sense, the lived experiences of youth who use tramadol can act as a barometer for understanding structural changes in society. Second, in the African postcolonial context in particular, youth has come to indicate “being disadvantaged, vulnerable and marginal in the political and economic sense” [ 42 ]. The fact of marginalisation and disadvantage was described by several interview participants, some of whom described intense despair associated with the condition of youth in Ghana. When I asked one of the interviewees about her hopes for the future as a young person in Ghana she responded:

If I talk about the education side, I really do not have hope because there are a lot of graduates home. And then the maximum of salary some of these graduates get is like 1500 cedis [240 USD] a month. How much is your water bill? Light bill everything? (A1).

Despite such stories of gloom, scholars have sought to explore the condition of youth on the continent not simply as hopeless stories of despair but to recognise within these realities of disadvantage and marginalisation “the diversity of experience as well as the agency and creativity of young people as they try to overcome serious everyday challenges” [ 43 ]. In the context of African youth’s continued challenge to governmental and other authorities by seeking to shape their own destinies and create new ‘youthscapes’ [ 44 ] and spaces for self-fashioning [ 45 ], I start by problematising how the issue of tramadol was framed in media discourses as a problem of ‘youth irresponsibility’. Following this, I explore how such framings fed into the sorts of solutions often proposed by the government and the media. I then contrast this discourse with the lived experience of youth who use tramadol many of whom indicated that palpable pain lay at the heart of their drug use. Interpreted in the context of ethnographies of pain, I argue that tramadol is used to respond to physical and non-physical pain.

4.2 Tramadol consumption as individual moral failure among youth

The primary mode of explanation employed by the media to make sense of the rise in tramadol consumption has been that it is abused because of individual moral failings. Several newspaper stories offered a plethora of explanations on why youth may abuse tramadol ranging from senior high school athletes who have “resorted to the abuse of the drug, claiming it enhances their performance” ( All Africa 4.7.2017) [ 46 ] to multiple media stories explaining that “the youth including students also take the drug to exert their strength when having sexual intercourse with their partners while others take it just for pleasure” ( Ghana News Agency 30.11.2017) [ 47 ].

In these morally tinged discourses, the media highlighted that people “knowingly used the drug for recreational and aphrodisiac purposes” ( Ghana News Agency 8.3.2018) [ 48 ]. These discourses were meant to galvanise societal hatred for tramadol users and therefore relied on ideas of promiscuity that would offend the social sense of morality. For example, in an article on drug confiscation in the Ashanti region, an official of the Food and Drugs Authority asserted that “some of the reasons for the abuse of the drug included supposed enhancement of sexual drive and prolonged ejaculation” ( Ghana News Agency 12.4.2018) [ 49 ]. While it might be the case that some people use tramadol for sexual enhancement [ 17 ], there was an overemphasis on this dimension. Indeed, most stories were focused either on connecting tramadol to sex or crime. Almost half of the news stories reviewed were about crime and arrests of young people with the drug in their possession. Interestingly, none of the interviewees in this research reported being arrested. Despite the overemphasis on sex, I found through interviews that few people use tramadol solely for sexual reasons (only one interviewee mentioned sex as an important reason for his use of tramadol).

Additionally, a neo-traditionalist discourse was invoked to explain tramadol use as a function of moral weakness. There were references by chiefs, queen mothers, religious leaders and opinion leaders who regularly emphasised “the beauty of innocence” and highlighted the necessity for “cultural learning that instils morals, values and norms in the children” as solutions to the tramadol challenge ( Ghana News Agency 24.11.2018) [ 50 ]. According to these authorities, use was on the rise because parents failed to instil morals in their children. The moral discourse often involved the older generation decrying falling moral standards in the country and was so entrenched that even some academic sources relied on this framing as exemplified in Elliason and colleagues [ 14 ] who concluded that “the moral upbringing of the youth” is responsible for the tramadol trend.

It is important to state these discourses explicitly because they heavily shaped what were perceived as the solutions to the problem of tramadol use: education or punishment. By framing it as a problem of youth who simply were morally corrupt, authorities often advocated for campaigns to “educate the youth” on the dangers of consumption and the moral imperative to avoid abusing the drug. Regulatory authorities “appealed to parents to advise their children to desist from the use of the drug since it is destroying a greater number of them” ( Daily Guide 3.8.2017) [ 51 ]. When such persuasion failed to yield the desired results a sort of ‘war on drugs’ approach was adopted. The health minister issued an executive instrument on 26 September 2018 (EI 168) banning the sale of tramadol. The instrument also made 250 mg doses illegal although stores could still sell 50 or 100 mg doses. Finally, it was converted to a prescription drug and several newspapers reported on police swoops to arrest youth who continued to use tramadol. Unfortunately, these ‘solutions’ often failed to target some of the underlying root causes of use and most of them also failed to adopt sustainable approaches. For example, during interviews drug regulators indicated that for youth who may have become addicted to tramadol appropriate solutions would have been to offer them access to rehabilitation centres. According to one regulator however these more long-term approaches were not favoured by government. The reason such solutions received less attention is summarised by a mental health nurse who described Ghana’s mental health system inadequacies:

[In Ghana] mental health itself has been relegated to the background to the extent that even the practitioners are stigmatised… How many traditional government facilities do we have in terms of hospitals that respond to the needs of the mentally ill? Only three in the whole country. And two of them are located down south here, Ankaful and Pantang (HCP 3)

Thus, throughout the discussions on tramadol as a problem of youth irresponsibility, authorities failed to understand why the youth use tramadol or to focus on youth-informed structural solutions to tramadol use. In this sense the moralising discourses that have been adopted by the government and other stakeholders have served to obscure the fact that mental health and addiction services are woefully inadequate in the country.

Famous Ghanaian cartoonist, Tilapia, satirically depicted some of the main supposed motivations for tramadol use; namely sex (a woman runs away from a rather virile young man) and feeling ‘high’ ( Fig 2 ). Tilapia also satirically showed how drug store owners laughed through it all as they made money (for example, although the law illegalised 250 mg, users could simply buy multiple 50 mgs to get the same ‘high’). (See: Tilapia, 2018)

Cartoon by Ghanian artist Tilapia da Cartoonist, April 2018. Reproduced with permission from Tilapia da Cartoonist.

https://doi.org/10.1371/journal.pgph.0001045.g002

4.3 Pain as a fundamental reason for tramadol use

The discourses above represent some of the ways the Ghanaian news media have understood and reported on the issue of tramadol use. The reports unfortunately paid less attention to the issue of pain which is problematic since a complex set of factors beyond individual choice often determine drug use and addiction [ 22 ]. More importantly discourses that marginalise those who use drugs deserve to be critically assessed because “targeting particular groups of drug users commonly reflect points of social apprehension and serve to enhance the social control and exploitation of subordinated ethnic, class, gender, or other groups characterised as a threat to the status quo” [ 26 ]. In the case of tramadol use in Ghana, this insight suggests that one ought to approach some of the media reports with some scepticism. In the remainder of the article, I argue that a fundamental reason young people in Ghana use tramadol is pain, although other important reasons exist. Using this focus, we can humanise those who use it and appreciate the complex contextual drivers of use beyond moral discourses. Attention to pain also serves as a critique of current policy solutions for eradicating tramadol use.

Pain is a fundamental part of the human condition. It has been of interest to scholars in varied disciplines from philosophy to anthropology because it is a “basic existential fact of our distinctly human way of being-in-the-world. To be human is to be vulnerable to both the possibility and inevitability of suffering pain” [ 52 ]. Understanding, interpreting and describing someone’s pain thus requires attention to the fact that “a person’s experience of pain is multi-dimensional, relating to culture, emotion, mind and body” [ 53 ].

The approach of contextualising pain, while useful, has historically been problematic because anthropological and medical interests in studying it from a cultural perspective sometimes led to the creation of stereotypes. For example, Black slaves and plantation workers were considered impervious to pain because of their supposedly “dulled sensitivities” arising from a less-developed brain [ 54 ], while Jews and Italians were described as “tending to exaggerate their pain experience” [ 55 ]. Some of these patently racist understandings of pain have unfortunately survived into the present leading to pervasive undertreatment of pain for Black people in settings such as the USA [ 56 ].

Despite these unfortunate academic attempts at understanding pain and the negative ongoing effects of such studies, critical accounts exist on the importance of adopting pain as an analytical entry point for exploring individual lived experiences. According to Arthur Kleinman [ 23 ] pain “indexes” the “embodiment of cultural categories of distress” and can help us “understand how the bodily experience itself is influenced by meanings, relationships and institutions.” I approached the study of tramadol by trying to ‘elevate’ pain to see what it indexes. During interviews I often asked participants about pain and how it shapes their use. By the end of the research process, it became apparent that many young people in Ghana use tramadol to alleviate two kinds of pain.

Unlike the media portrayals of tramadol use as a moral issue, most of the youth I interviewed indicated that they use it to relieve either physical or non-physical pain ( Fig 3 ). Physical pain simply refers to bodily pain often arising from the work one does. Research participants used tramadol to ease pain from their strenuous work. One of the interviewees, a painter who also often worked as a labourer and had used tramadol for a long time, noted:

Sometimes there are some works that I do which are very hard and when I take in that [tramadol] I don’t feel that pain. I can do the work over and over and I am not going to mess it up (W1).

https://doi.org/10.1371/journal.pgph.0001045.g003

Another interviewee, a welder and sprayer, noted that “with the drug when you are working you feel no pain and you do not feel weak, you do not feel anything, you just feel ok”. (T3) These descriptions, contrary to some of the media discourses, cohere with other literature on drug use in Africa that suggest that many young people use drugs such as cannabis for “deadening the pain of difficult work or alleviating the boredom of repetitive activities” [ 57 ]. In this sense, one of the main reasons why young Ghanaians use tramadol is to reduce physical pain connected to work.

Many young people also explained that they used tramadol to ease non-physical pain. In these cases, the drug is used as a way of navigating the condition of youth itself or to help deal with life struggles such as the death of a parent, while others use it to feel a sense of hope or to deal with boredom. This kind of pain is similar to that described by Weiss [ 58 ] in The Barber in Pain . It is pain that is not necessarily bodily but emerges from social structures. The youth described by Weiss in the barber shops of Arusha, Tanzania did not necessarily turn to drugs to deal with the pain of feeling marginalised but turned to music and work, and for them pain “presents an affirmation of one’s ongoing confrontation with obstacles, a process of grappling with life’s troubles that define existence itself” [ 58 ]. Additionally, while pain indexes social suffering it can also foster solidarities, where people “share and distribute pain” as Fullwiley [ 59 ] found for sickle cell sufferers in Senegal.

Many of the participants I interviewed described non-physical pain related to dropping out of school, losing a parent, not having a stable job or simply not feeling that the transition to adulthood was working out as they would have hoped. They often explained that apart from pain in the body there was “another pain” in their life for which tramadol was a panacea. Consider the following statement from a 27-year-old participant who had dropped out of school after completing his junior high school education because his parents could not afford to pay his school fees. He argued that tramadol gave him a certain ‘feeling’ he wanted to hold on to:

It gives you a certain feeling. It gives you vim. It makes you feel like you can still make it. You may see your colleague riding a motorcycle past and if you look at them you can have the feeling that perhaps even today you could make it. Personally, for me what used to happen was that whenever I would see a colleague like that it always gave me a certain vim to work more while having the same mood (T3)

Similarly, another participant described how his parents’ divorce coupled with poverty and feelings of dislocation led him to drug use:

The reason why I’m taking [tramadol], I’m looking back, it was because of poverty that the disagreement came between my mother and father, but if I become rich, I can solve that disagreement. If I get money… the money I have, if it increases, then the pain can diminish in my heart, because both of them are aged now. (T4)

According to Honwana [ 43 ], many young people in Africa today are confronted with waithood, “a prolonged and uncertain stage between childhood and adulthood that is characterised by inability to enter the labour market and attain the social markers of adulthood.” This reality is a by-product of global neoliberal processes that have made work elusive in many parts of Africa [ 60 ] causing alienation among many young people who can only eke out an existence. The evidence from the interviews suggests that many young people experience waithood—or even ‘boredom’ as described by Masquelier [ 61 ] for young people in Niger—in a manner that predisposes them to the use of tramadol as a coping mechanism. Like the youth in Dar es Salaam [ 62 ] who turn to heroin to deal with the difficult and prolonged transition to adulthood, the Ghanaian youth I interviewed have turned to tramadol to deal with some of the challenges of being young in Ghana today. In this sense their drug use partly represents a response to pain, waithood and the condition of youth.

4.4 Beyond pain

While most of this article has focused on pain and moral discourses, there are important variations in the contexts of tramadol use and interviewees also highlighted issues beyond pain. Some of these issues have been examined in extant literature on tramadol use in Ghana [ 14 , 16 , 17 ]. Briefly, reasons discussed by interviewees for tramadol use beyond pain were desires for pleasure or to alter one’s mood, the use of tramadol as an antidote to boredom, a desire not to appear lazy in the workplace and the use of tramadol as a form of sociality and to gain a sense of belonging.

Almost every participant indicated that they were aware of the unfavourable societal views of tramadol users and expressed a desire to be understood and seen as ‘normal’ people. Indeed, contrary to media representations of those who use tramadol as simply feckless and irresponsible, many youths expressed fears about the possibility of becoming addicted to tramadol. They acknowledged the dangers of addiction and balanced these with the pleasure tramadol gives and or the utility of the drug in improving their ability to function in the workplace. When asked why he used tramadol, one of the respondents noted that it played the dual role of making him happy and not feel lazy:

If I take that one [tramadol], I just have happiness, if am working, am just fine, I will not be having laziness in me or be sleepy. (T1)

The only female respondent similarly described how tramadol made her feel a sense of ‘calmness’. She noted that while this calmness was desired, she observed she needed to increase her dosage to experience this emotion and hinted at fears of addiction. She noted in her interview:

It makes me feel really calm. I sleep, by the time I wake everything is ok. If you get to this stage like my body, get[s] use[d] to the 100mg and we’ve had to increase it though it is not good, I think! For my system, for my own good. (A1)

Many youths highlighted fears of negative societal perceptions and of addiction. In some cases, fear of addiction was seen as a possible reason to quit the use of tramadol. When one participant was asked if he would quit using tramadol he responded:

Why I will stop using tramadol is that you can get addicted and when you don’t get it to take you may fall ill. The drug may also drain your body fluid (T4)

These fears of addiction coupled with worries about negative societal views of those who use tramadol were highlighted by interview respondents. One responded particularly noted how her mother and people in drug stores were taken aback when they realised she used tramadol:

They think everyone abuse it, like they just look at you in some certain way like, ‘she looks okay, why is she requesting for tramadol?’ There’s been an impression on the use of tramadol, that people that use it abuse it. And then they take it in larger doses. I do but I don’t take it that much, but people can take 200gm of it just for, I don’t know why they do that, so it causes that perception. In fact, even home, if am taking the medicine and say oh mommy this is tramadol. I am taking tramadol; she will say like eiii [exclamation] you’re taking tramadol for what? (A1)

The worries about the possibility of addiction as well as anxieties regarding negative societal perceptions of those who use tramadol were seen by some as possible reasons to quit using the drug. Beyond the moralising discourses described above such fears are partly justified because extant research shows that the public often has unfavourable views of those who use drugs when compared for example to people with (other) mental illnesses [ 63 ]. The factors described (pleasure, boredom avoidance, a desire not to appear lazy etc.) above while not directly related to pain also influenced tramadol use and highlight the complex nature of use among youth. Fears regarding addiction and awareness of negative societal views of tramadol users all highlight the humanity of tramadol users and reveals them to be young people seeking to find their place in the world rather than criminals or morally bankrupt people as represented by some in the media.

5. Conclusion

There is little doubt that the abuse of any drug can be dangerous and associated with addiction. Nonetheless dealing with the challenges of drug abuse among youth in marginalised contexts should be guided by a “harm reduction approach” [ 64 ] rather than the “tough on crime and anti-drug” [ 26 ] approach that has been adopted in Ghana thus far. In March 2020 Ghana signed the Narcotics Control Commission Bill [ 65 ] into law, signifying a major step towards viewing drug use and addiction as public health concerns rather than criminal justice problems. This shift is likely a move towards harm reduction and has the potential to play an important role in responding to drug use among Ghanaian youth.

Interpreted more broadly, tramadol is one of many ways Ghanaian youth are responding to social marginalisation. Like their predecessors who alarmed colonial authorities by “rebelling” [ 66 ], using tramadol is a way of navigating difficult social and economic conditions as well as coping with the prolonged transition to adulthood. In early May 2021, the Twitter hashtag #fixthecountrynow was used by several young Ghanaians to register their displeasure at the ongoing economic and social difficulties facing the country. Within a couple of weeks many young people were tweeting about bad roads, dumsor (power outages), water crises and other socioeconomic problems. The rise in tramadol use should be understood at least in part, as a reaction to economic realities created by decades of structural adjustment and neoliberal economic policies [ 9 ] that limit opportunities for decent work thus forcing young people to use drugs. These reactions merit structural intervention to improve the social determinants of health and to curb the potential dangers of addiction by youth. An important reason for opioid use among Ghanaian and West African youth is pain rather than immorality as portrayed by authorities and this calls for a rethinking of the sorts of solutions prescribed for dealing with the challenge of opioid use. Additionally, young people sometimes use tramadol in a non-problematic fashion thus necessitating proper engagement with youth as the country works on responding to the use of tramadol and other drugs.

Supporting information

S1 checklist. coreq checklist..

https://doi.org/10.1371/journal.pgph.0001045.s001

S1 Table. Combined analysis and codes.

https://doi.org/10.1371/journal.pgph.0001045.s002

S1 Text. Interview questions.

https://doi.org/10.1371/journal.pgph.0001045.s003

S2 Text. Inclusivity in global research.

https://doi.org/10.1371/journal.pgph.0001045.s004

Acknowledgments

I thank Prof David Pratten (Head, Oxford School of Anthropology and Museum Ethnography) for helpful comments on earlier versions of this manuscript. I am also thankful to Mr. Wisdom Acheampong (Health Administrator, Princess Marie Louie Children’s Hospital, Accra) and Malik (tricycle rider, Tamale) for support during participant recruitment.

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Drug abuse among the youth in ghana, ha brown-acquaye.

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Journal Identifiers

Social Science
Social Policy
Drug Policy

Drugs and the Youth Ghana's Drug Policies in a Changing World

January 2018
In book: Drug Policies in Africa : What Works (pp.35-52)
Publisher: Centre for Human Security and Dialogue

University of Professional Studies

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DRUG ALCOHOL DEPEN

J SCHOOL HEALTH
Reagan G. Cox MPH
MBA Lei Zhang PhD
Daniel R. Bender MS

Victoria E. Wells
Peter M. Lewinsohn

John R. Seeley

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Below 20 years

20 – 24 years

25 – 29 years

30 – 35 years

Primary

J.H.S.

S.H.S.

Tertiary

Employed

Unemployed

Islam

Christianity

Single

Married

Source: fieldwork, 2020

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Drugs and the Youth Ghana's Drug Policies in a Changing World

2018, Centre for Human security

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The history of the human race also includes drug usage and perhaps misuse. In and of itself, drug usage is not a bad thing; in fact, certain drugs have been a medical godsend. Herbs, roots, and bark leaves have alleviated pain and managed illness from time immemorial. According to history, the Chinese used opium to treat diarrhoea before the 18 th century. Drug misuse is a worldwide issue that threatens the lives of people, society, and several nations' political stability and security. The use of illegal drugs has expanded globally, and the key global trend is the rising availability of various types of narcotics to an ever-expanding user base. Concerning is the fact that youngsters seem to be the new market for the global pharmaceutical business. According to the World Health Organisation (WHO), substance abuse is the harmful or risky use of psychoactive substances, such as alcohol and illegal drugs. Psychoactive drug usage may develop into dependency syndrome, which is the continuous, repetitive, and persistent use of the substance despite its adverse effects, resulting in the prioritization of substance use above other activities and responsibilities. Generally, drugs are helpful when properly used and destructive when misused or abused, but most youths are guilty of substance abuse (Mohammad, 2014). The use of illicit substances is a major public health problem in high-income countries like the U.S. However, this problem of illicit substance use has spread rapidly to middle and low-income countries, where most youth and adolescents are actively engaged in this illegal practice (Aliyu, 2014 & Mohammed, 2014). Many authors and researchers have shown that many contributing factors lead to substance abuse among the youth. Adolescence is the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique stage of human development and an important time for laying the foundations of good health. Adolescents experience rapid physical, cognitive and psychosocial growth. This affects how they feel, think, make decisions, and interact with the world around them. Despite being considered a healthy stage of life, there is significant death, illness, and injury in the adolescent years. Much of this is preventable or treatable. During this phase, adolescents establish patterns of behaviour, for instance, related to diet, physical activity, substance use, and sexual activity that can protect their health and the health of others around them or put their health at risk now and in the future (WHO, 2022). Adolescence is characterised by increased adventurous tendencies and peer influences.

Dr. Janvier Rugira

The study focused on exploring trends of social factors influencing adolescents' substance abuse as they relate to drug policies in member states of the East African Community i.e. Tanzania, Kenya, Burundi, Uganda, and Rwanda. A comprehensive literature search was conducted on Academic Search Premier (Cinahl, ERIC, PsycInfo, PsycArticles, SocIndex), International Theses & Dissertations (ProQuest), ScienceDirect, Emerald, SAePublications, SabinetOnline, JSTOR, Google Scholar, Scopus, and RefWorks. In terms of social factors, the study reveals that loss of parents, forced career choice, low level of education, unemployment, idleness, poverty, life stress, peer influence, curiosity, and dysfunctional family state contribute to drug abuse among EAC adolescents. Drug abuse is linked to national insecurity, specifically among Internally Displaced People in the region. The EAC countries have ratified the World's Single Convention on Narcotic Drugs of 1961; all shares the protocol on combating drug trafficking in African Region and that of EAC of 2001. The link between drug policies and drug abuse prevalence was established in this study. Kenya, Uganda, and Tanzania have drug control Acts which Rwanda and Burundi do not have. Kenya and Uganda have independent control commissions to control drug abuse, which Burundi, Rwanda, and Tanzania are lacking.

SOCIOLOGICAL STUDY OF DRUG ABUSE AMONG YOUTH

Suleiman A H M E D Bakori

South African Journal of Child Health

Adebanke Olawole-Isaac

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Newspaper Coverage of Substance Misuse and Other Drug-Related Behaviors in Ghana: A Content Analysis of Health Communication

Original Article
Published: 15 March 2021
Volume 20 , pages 1768–1792, ( 2022 )

Cite this article

Christina Barnett ORCID: orcid.org/0000-0002-5283-8097 1 ,
Vivian Dzokoto 1 ,
Viviette Allen 2 ,
Annabella Osei-Tutu 3 ,
Hortance Houngbeke 4 &
Samuel Hanu 5

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Six Ghanaian newspapers with the widest readership and distributions were selected for analysis to examine health communication themes and strategies related to alcohol and/or substance misuse and other drug-related behaviors in Ghana. Newspapers were manually searched using relevant keywords. We used thematic analysis to examine 90 articles that were identified. Content themes included (1) legal consequences, (2) adverse effects, (3) change motivation, and (4) help and support. Communication strategies included (1) articles about high-profile individuals or events, (2) narratives, (3) use of rhetoric, and (4) sensationalism. The legal consequences of misusing substances and using illicit substances were the most prevalent themes. Sensationalism was the most prevalent communication strategy. We address the benefits and limitations of the ways in which Ghanaian print media shapes the narrative about substance misuse.

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Christina Barnett & Vivian Dzokoto

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Mental Health Authority Ghana, Accra, Ghana

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Barnett, C., Dzokoto, V., Allen, V. et al. Newspaper Coverage of Substance Misuse and Other Drug-Related Behaviors in Ghana: A Content Analysis of Health Communication. Int J Ment Health Addiction 20 , 1768–1792 (2022). https://doi.org/10.1007/s11469-020-00479-7

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Accepted : 27 December 2020

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DOI : https://doi.org/10.1007/s11469-020-00479-7

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Prevalence, Reasons, Predictors, Perceived Effects, and Regulation of Alcohol Use among Children in Ghana

Sylvester kyei-gyamfi.

1 Department of Children, Ministry of Gender, Children and Social Protection, Accra, Ghana

Nii Wellington

2 Development Education Centre–Ghana, Box M103, Ministries, Accra, Ghana

Frank Kyei-Arthur

3 Department of Environment and Public Health, University of Environment and Sustainable Development, Somanya, Eastern Region, Ghana

Associated Data

The raw data for the findings of this study are freely available from the corresponding author upon request.

Early initiation of alcohol consumption increases the risk of alcohol dependence and adverse health outcomes. Consequently, nations have enacted laws to make alcohol unlawful to be purchased by, sold to, or used in public by children. This study examined the lifetime prevalence of alcohol use among children and their reasons for consuming alcohol. In addition, the study investigated predictors of alcohol consumption and the effects of alcohol use on children. Finally, it examined the effectiveness of measures in place for regulating the sale and use of alcohol by children in the country. A total of 5024 children between the ages of 8 and 17 were sampled across the ten regions of Ghana using a cross-sectional convergent parallel mixed method. Children were interviewed with a semi-structured questionnaire, while focus group discussions were held with children, parents, and key informants. Lifetime prevalence of alcohol consumption was measured by “have you ever taken alcohol?”. The study revealed that lifetime alcohol consumption was less prevalent (6.6%) among children. Sex, age, and region of residence were significant predictors of lifetime alcohol use among children. More than half of the children who reported ever taking alcohol were first introduced to drinking by friends, and more than six in ten children claimed having been intoxicated after drinking alcohol. The findings further revealed that efforts to control the sale and consumption of alcohol by children have proven difficult despite the existence of laws, policies, and national regulatory structures. While regulations on alcohol sales and consumption have been difficult to implement in rural areas, they have been successful in urban areas because institutions there ensure rigorous adherence to the regulations. The study encourages national organizations with responsibility for child protection and development to step up their regulation, investigation, and information-sharing efforts to discourage and limit children from purchasing and consuming alcohol.

1. Introduction

When a person drinks alcohol while under the legal drinking age, it is referred to as underage drinking. Early alcohol usage is linked to future dependency, health problems, and poor ability to interact with others [ 1 ]. Globally, about three in ten (26.5%) children between the ages of 15 and 19 have been estimated to have ever consumed alcohol [ 2 ].

In several nations, alcohol use starts before the age of 15; hence, some nations have passed laws making it illegal for children (persons under the age of 18) to buy, sell, or consume alcohol in public [ 2 , 3 ]. Ghana is among the nations with legislation prohibiting the consumption of alcohol by children. The Liquor Licensing Act of 1970 (Act 331) establishes an age limit of 18 or older for alcohol consumption in Ghana [ 4 ]. To regulate alcohol usage and fight underage drinking nationwide, Ghana's government also established the National Alcohol Policy and the Narcotics Control Board (NACOB).

Oshodin [ 5 ] highlighted that males were more likely than females to drink alcohol in traditional African societies. According to the author, indulgence in excessive consumption of alcohol and intoxication received severe punishment, and women and children were discouraged from taking alcohol. However, alcohol drinking habits are changing in many African societies as a result of societal changes, economic progress, and the expansion of the alcohol industry [ 6 ]. The number of children who engage in alcohol consumption has increased as a result of these changes, and Ghana is no exception.

Studies in Ghana show a rise in the prevalence and involvement of children in alcohol usage [ 7 , 8 ]. The 2016 Multiple Indicator Cluster Survey (MICS), for instance, indicates that 22% of males and 19% of females between the ages of 15 and 19 had, at some point, drunk alcohol [ 9 ]. Children abusing alcohol is a public health issue that has repercussions for the country's young population's welfare and development [ 10 ]. Bonnie [ 11 ] revealed that underage drinking has a number of negative effects, such as accidental death and injury, poor academic performance, and strained relationships as a consequence of alcoholism and addiction. Early alcohol consumption is also associated with an increased likelihood of adult alcohol dependence and alcohol use disorders [ 12 , 13 ]. In addition, drinking alcohol has been linked to an increase in youth-related violence [ 2 ].

Although drinking alcohol has detrimental effects on children, most studies conducted in Ghana have only looked at the general population [ 14 – 17 ]. In addition, the few studies on children and young people are not representative of the entire country [ 7 , 8 , 18 ]. For instance, a study by Hormenu et al. [ 7 ] among in-school children aged 10–15 in the central region found that 42.3% had ever consumed alcohol. Also, a study by Amoah et al. [ 18 ] among senior secondary students in Bono East region in Ghana found that 22.2% of students currently consume alcohol, while 27.9% had ever consumed alcohol. Thus, there are limited studies focusing on alcohol consumption among children using nationally representative data. Studying alcohol consumption among children using nationally representative data will help researchers and policymakers to understand better the phenomenon of alcohol consumption among children, which will help to develop effective interventions to address the phenomenon.

In light of this, the study examined the lifetime prevalence of alcohol consumption among children and the reasons underlying their alcohol use. The study additionally investigated predictors of alcohol usage and the effect of alcohol use on children. The effectiveness of policies in place for regulating alcohol sale and use by children in the country was also examined.

1.1. Hypothesis Development

Previous studies have shown that the prevalence of alcohol consumption among children differs by socio-demographic characteristics such as sex and age [ 2 , 7 , 19 , 20 ]. For instance, previous studies have reported that alcohol consumption is more prevalent among male children than female children [ 8 , 9 , 21 ]. In addition, research has found a positive relationship between children's age and alcohol intake [ 9 , 22 , 23 ]. Based on these studies, this study tested two hypotheses as listed as follows:

Hypothesis 1 (H1): males are more likely to have ever consumed alcohol than females
Hypothesis 2 (H2): older children are more likely to have ever consumed alcohol than younger children

2. Materials and Methods

2.1. study design and sampling procedure.

This study used a cross-sectional convergent parallel mixed-method design to understand the phenomenon of alcohol consumption among children aged 8–17. For the purpose of this study, persons aged 8–17 are defined as children. A convergent parallel mixed-method design simultaneously gathers quantitative and qualitative data to understand a social phenomenon [ 24 ]. The study was conducted by the Department of Children (DOC) of the Ministry of Gender, Children and Social Protection (MoGCSP) in the 10 regions of Ghana. A multistage sampling procedure was used to sample children aged 8–17. In the first stage, 20% of districts in each of the country's 10 regions were chosen based on child protection issues such as child marriage and child labor. In 2018, Ghana had 216 districts; 43 districts (20%) were selected. In the second stage, 15 enumeration areas (EAs) were randomly selected in each of the 43 districts. In total, 645 EAs were selected. In the third stage, children aged 8–17 in each EA were selected proportionate to the district's size. It is worthy of note that in each household, only one child aged 8–17 was selected.

2.1.1. Quantitative Data

For the quantitative data, a semi-structured questionnaire was administered face-to-face to children aged 8–17. In total, 5,024 children aged 8–17 were interviewed.

2.1.2. Qualitative Data

Ten focus group discussions (FGDs) with children between the ages of 8 and 17 were conducted as part of the qualitative data collection. The FGDs were held in ten towns, each in a region, in convenient sites decided upon by the participants. Each FGD had a maximum of 14 participants. Also, ten FGDs were held with parents of children aged 8–17 at convenient places in ten different towns. In addition, fifty key informant interviews (KIIs) were conducted at convenient locations with representatives from a range of Government Ministries, Departments, and Agencies (MDAs), and Metropolitan Municipal and District Assemblies (MMDAs).

2.2. Study Setting

In order to fulfill Ghana's international reporting requirements under the Convention on the Rights of the Child (CRC), the Government of Ghana through MoGCSP conducted a study on the living circumstances of children in Ghana. Ghana is a nation in sub-Saharan Africa, bordered to the north by Burkina Faso, to the south by the Gulf of Guinea, to the east by Togo, and to the west by Cote d'Ivoire. Ghana's population was estimated at 30.8 million as of 2021 by the Ghana Statistical Service (GSS) [ 25 ], with 6.8 million (22.1%) of the population being children under the age of 17. Ghana now has 16 administrative regions, an increase of 6 regions from 2018, the year the study's data were gathered.

2.3. Measurement and Variables

The dependent variable for the study was the lifetime prevalence of alcohol consumption, which was measured with the question, “Have you ever taken alcohol?”, with the response options being 1 = yes, and 2 = no.

The independent variables for this study included sex (male and female), age (8–10 years, 11–13 years, and 14–17 years), educational attainment (not in school, primary, junior high school (JHS), and senior high school (SHS)/vocational/technical/commercial, and tertiary), religion (Christian, Muslim, Traditional, and no religion), and region (Greater Accra, Central, Western, Eastern, Volta, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West).

Alcohol consumption was also measured qualitatively by asking children the types of alcohol children consumed and where they purchased alcoholic beverages. In addition, key informants were asked about measures by the Government of Ghana to protect children from substance abuse, especially regulations on alcohol sales and consumption by children. Parents were also asked about the challenges associated with the regulations on alcohol sales and consumption.

2.4. Data Collection

This study is a part of a comprehensive study by the MoGCSP on the living circumstances of children in Ghana [ 26 ]. Living and household arrangements, education and training, social amenities, children's rights, health and healthcare, sexual and reproductive health, usage of the internet and social media, child employment, and children's goals and aspirations were some of the subjects covered by the comprehensive study.

It took seven months to gather the data, starting in April 2018. A one-day workshop was held to train field assistants on how to interview key informants and conduct FGDs with children aged 8–17 as well as administer the semi-structured questionnaire to children aged 8–17.

2.5. Statistical Analysis

Descriptive analyses (univariate analyses), such as frequencies and percentages, were used to describe the children socio-demographic characteristics, lifetime alcohol consumption, ever been drunk, initiation into alcohol consumption, frequency of alcohol use, reasons for drinking alcohol, and perceived effects of alcohol consumption. Pearson's Chi-square and Fisher's exact tests (bivariate analyses) were employed to examine the association between the sociodemographic characteristics of respondents and the dependent variable (ever taken alcohol). Fisher's exact test is recommended when a contingency table cell has an expected frequency of less than 5 [ 27 – 29 ]. In addition, Pearson's Chi-square and Fisher's exact tests were employed to examine the association between reasons for drinking alcohol and the sex of children and the perceived effects of alcohol consumption and the sex of children, respectively.

A binary logistic regression (multivariate analysis) was performed to identify the predictors of children's lifetime alcohol usage. All the quantitative data analyses (univariate, bivariate, and multivariate analyses) were carried out using the Statistical Package for the Social Sciences (SPSS) version 26. All variables were statistically significant at 95% confidence interval ( P < 0.05).

All interviews were audio-taped and transcribed verbatim from the local languages (such as Twi, Ewe, and Dagbani) to English. Thematic analysis was used to analyze all transcripts. All transcripts were read several times to get a general sense of children's experiences. Statements made by respondents that were pertinent to the study's objectives were given codes. Similar codes were grouped into sub-themes, and similar sub-themes were grouped into themes.

2.6. Ethical Considerations

The National Child Protection Committee (NCPC) of the DOC of MoGCSP gave approval for the study. The data collected for this study are part of a national monitoring exercise to evaluate the effectiveness child rights adherence in Ghana. The data collection process adhered to the Helsinki Declaration's principles. Children's rights were observed by protecting their privacy and anonymizing the collected data. All respondents (children, parents, officials of parents, and officials of MDAs and MMDAs) who participated in the study gave informed consent before being interviewed.

3.1. Socio-Demographic Characteristics of Respondents

Table 1 shows the socio-demographic characteristics of the children sampled. Males made up more than half of the participants (51.1%). Most children (75.1%) were Christians, and a higher proportion were aged between 14 and 17 (43.7%). More children aged between 14 and 17 had significantly ( P ≤ 0.001) ever consumed alcohol than those aged between 8 and 10 and those aged 11 and 13. More children were in primary school (42.1%). However, a higher proportion of children in SHS had significantly ( P ≤ 0.001) ever consumed alcohol than those in other educational categories. Also, more children resided in the Brong Ahafo region (14.7%). However, more children who resided in the Volta region had significantly ( P ≤ 0.001) ever consumed alcohol than those in other regions.

Socio‐demographic characteristics of respondents.

Variables	(%)	Ever taken alcohol
Variables	(%)	Yes (%)	No (%)	value

Male	2566 (51.1)	181 (7.1)	2385 (92.9)	0.215
Female	2458 (48.9)	152 (6.2)	2306 (93.8)


8–10	1330 (26.5)	19 (1.4)	1311 (98.6)	≤0.001
11–13	1497 (29.8)	62 (4.1)	1435 (95.9)
14–17	2197 (43.7)	252 (11.5)	1945 (88.5)
Mean ± Standard deviation	12.9 ± 3.0


Not in school	27 (0.5)	0 (0.0)	27 (100.0)	≤0.001
Primary	2116 (42.1)	50 (2.4)	2066 (97.6)
JHS	1584 (31.5)	143 (9.0)	1441 (91.0)
SHS	1183(23.5)	130 (11.0)	1053 (89.0)
Tertiary	114 (2.3)	10 (8.8)	104 (91.2)


Christian	3771 (75.1)	260 (6.9)	3511 (93.1)	0.424
Muslim	1083 (21.6)	60 (5.5)	1023 (94.5)
Traditional	103 (2.1)	8 (7.8)	95 (92.2)
No religion	67 (1.3)	5 (7.5)	62 (92.5)


Greater Accra	360 (7.2)	31 (8.6)	329 (91.4)	≤0.001
Central	474 (9.4)	39 (8.2)	435 (91.8)
Western	377 (7.5)	25 (6.6)	352 (93.4)
Eastern	598 (11.9)	18 (3.0)	580 (97.0)
Volta	595 (11.8)	56 (9.4)	539 (90.6)
Ashanti	707 (14.1)	48 (6.8)	659 (93.2)
Brong Ahafo	738 (14.7)	43 (5.8)	695 (94.2)
Northern	722 (14.4)	35 (4.8)	687 (95.2)
Upper East	237 (4.7)	22 (9.3)	215 (90.7)
Upper West	216 (4.3)	16 (7.4)	200 (92.6)

∗ Fisher exact test.

3.2. Ever Taken Alcohol and Ever Been Drunk after Consuming Alcohol

Table 2 displays the responses from study participants about alcohol usage. According to Table 2 , nearly seven percent (6.6%) of children have ever consumed alcohol. Among those who had ever taken alcoholic beverages, the majority (63.4%) got drunk after consumption.

Distribution of ever taken alcohol and ever been drunk after consuming alcohol.

Variables		%

Yes	333	6.6
No	4691	93.4


Yes	211	63.4
No	122	36.6

3.3. Predictors of Alcohol Consumption among Children

Table 3 shows the variables that predict lifetime alcohol consumption among children. Respondents not in school and those in primary schools were merged for educational attainment since they did not contain enough cases for the multivariate analysis. Table 3 revealed that male children (AOR = 1.272; Wald test = 4.200; 95% CI = 1.011–1.601; P =0.040), children aged 11–13 (AOR = 2.666; Wald test = 11.000; 95% CI = 1.493–4.758; P =0.001), and children aged 14–17 (AOR = 8.088; Wald test = 33.160; 95% CI = 3.971–16.476; P ≤ 0.001) were significantly more likely to have ever consumed alcohol.

Predictors of alcohol consumption among children.

Variables	AOR	Wald	95% CI	value

Male	1.272	4.200	1.011–1.601	0.040
Female (RC)


8–10 Years (RC)
11–13 Years	2.666	11.000	1.493–4.758	0.001
14–17 Years	8.088	33.160	3.971-16.476	≤0.001


Not in school/primary	1.307	0.376	0.555–3.075	0.540
JHS	1.542	1.532	0.777–3.062	0.216
SHS/vocational/technical/commercial	1.411	0.978	0.713–2.792	0.323
Tertiary (RC)


Christian	0.983	0.001	0.383–2.525	0.971
Muslim	0.951	0.010	0.355–2.548	0.921
Traditional	0.984	0.001	0.298–3.249	0.979
No religion (RC)


Greater Accra (RC)
Central	0.818	0.607	0.493–1.357	0.436
Western	0.630	2.621	0.360–1.102	0.105
Eastern	0.320	13.592	0.175–0.587	≤0.001
Volta	1.052	0.044	0.655–1.689	0.834
Ashanti	0.739	1.523	0.457–1.195	0.217
Brong Ahafo	0.738	1.460	0.451–1.208	0.227
Northern	0.565	4.236	0.329–0.973	0.040
Upper East	1.044	0.021	0.579–1.883	0.885
Upper West	0.860	0.202	0.447–1.658	0.653

AOR = adjusted odds ratio; RC = reference category; CI = confidence interval.

However, children residing in the Eastern (AOR = 0.320; Wald test = 13.592; 95% CI = 0.175–0.587; P ≤ 0.001) and Northern regions (AOR = 0.565; Wald test = 4.236; 95% CI = 0.329–0.973; P =0.040) were significantly less likely to have ever consumed alcohol.

3.4. Initiation into Alcohol Consumption, Reasons, and Perceived Effects of Alcohol on Children

Children were asked when they first initiated alcohol consumption ( Table 4 ). Table 4 shows that more than half (53.5%) of children were initiated into alcohol consumption by friends. In contrast, 17.4% were initiated by elders in their family or household.

Initiation into alcohol consumption, reasons for drinking alcohol, and perceived effects of alcohol on children by sex of children.

Response	Frequency (%)	Sex of children
		Male	Female	-value
		Frequency (%)	Frequency (%)	-value

Friends	178 (53.5)	96 (53.9)	82 (46.1)	0.971
Elders in family/household	58 (17.4)	33 (56.9)	25 (43.1)
Party/ceremony	57 (17.1)	30 (52.6)	27 (47.5)
Drinking bar	40 (12.0)	22 (55.0)	18 (45.0)

Group culture	107 (32.1)	55 (51.4)	52 (48.6)	0.037
Boost confidence	72 (21.6)	37 (51.4)	35 (48.6)
Whet appetite for meals	62 (18.6)	42 (67.7)	20 (32.3)
Taking as medicine	50 (15.0)	21 (42.0)	29 (58.0)
As part of community/household ceremonial activities	25 (7.5)	13 (52.0)	12 (48.0)
Forget worries	17 (5.1)	13 (76.5)	4 (23.5)

Poor performance in school	131 (39.3)	71 (54.2)	60 (45.8)	0.709
Engage in misconduct or deviant acts	120 (36.0)	67 (55.8)	53 (44.2)
Makes you confident/stronger	24 (7.2)	11 (45.8)	13 (54.2)
Makes you forget your worries	24 (7.2)	13 (54.2)	11 (45.8)
Results in accidents and deaths	31 (9.3)	16 (51.6)	15 (48.4)
Makes you prone to disease infection	3 (0.9)	3 (100.0)	0 (0.0)
Total	333 (100.0)

According to the respondents ( Table 4 ), children consume alcohol for varied reasons, including group culture (32.1%), boost confidence (21.6%), whet appetite for meals (18.6%), and taking as medicine (15.0%). There is a significant association between the initiation of alcohol consumption and the sex of children ( P =0.037). A higher proportion of male children reported group culture (51.4%), boost confidence (51.4%), and whet appetite for meals (67.7%) as their main reasons for consuming alcohol than the females. However, more females mentioned taking alcohol as medicine (58.0%) as their main reason for consuming alcohol than males (42.0%).

When asked about the effects of drinking alcohol, 39.3% believed it causes children to perform poorly in school. In contrast, 36.0% believed it causes people to become deviants or misconduct themselves. In addition, respondents reported that alcohol consumption results in accidents and fatalities (9.3%), makes a person confident/stronger (7.2%), helps individuals forget their troubles (7.2%), and increases the likelihood of illness infection (0.9%).

3.5. Regulation of Alcohol Sale and Use among Children

Interviews with the officials of the Narcotic Control Commission (NACOC) revealed that measures in place for protecting children from substance abuse include the enactment of the Narcotic Control Commission Act, 2020 (Act 1019), which is an amendment of the Narcotics Drugs (Control, Enforcement and Sanctions) Law 1990 (PNDCL 236). The law bans narcotic drugs and also led to the establishment of the Commission, which has been successful in curbing the flow of drugs into the country. NACOC officials also mentioned that Ghana has signed and ratified various United Nations Conventions and Protocols on drugs. These include the 1961 Single Convention, 1971 Convention on Psychotropic Substances, 1972 Protocol Amending the 1961 Single Convention, and 1988 Convention against Illicit Trafficking of Narcotic Drugs and Psychotropic Substances. They went on to indicate that Ghana endorsed the international treaties to deal with issues related to drug control and other associated substances affecting young people, particularly children. Periodically, the NACOC and other state organizations, such as the Department of Social Welfare and the National Commission for Civic Education (NCCE), conduct public awareness programs in educational facilities, and communities to raise awareness of the negative impacts of drug and alcohol abuse. The followings are quotes from the NACOC officials to buttress the point:

Campaigns to raise community awareness of the negative consequences of alcohol abuse are frequently carried out by the National Commission for Civic Education (NCCE), NACOB and the Department of Children and the Department of Social Welfare under the Ministry of Gender and Children and Social Protection. (KII 5).

However, key informants explained that NACOB and other state institutions experience several challenges, including inadequate funds, affecting its capacity to fight alcohol and drug-related issues in the country. The followings are the views expressed by key informants:

The government finances NACOB and sometimes gets partnership funding from donors. However, we have inadequate funding, a major concern that needs to be addressed to enable us to carry out our respective mandates for effective outcomes in our operations. (KII 1).

Key informants at the Accra Psychiatric Hospital also highlighted that no therapy facility in the country is solely dedicated to providing service for children with alcohol and drug-related issues.

Most of the annual cases at the Accra Psychiatric Hospital are due to drug misuse among young people [including children]. The fact that most therapy facilities in the country only accept adults is the main cause for concern. It is really concerning that there is now no facility in the whole country for children. (KII 3).

Regarding alcohol sale and consumption regulation, key informants narrated that the Ministry of Health has adopted a National Alcohol Policy to harmonize all laws that exist to control the production, distribution, sale, promotion, and consumption of alcohol in the country. By regulating the production, distribution, sale, promotion, and consumption of alcohol, the new policy seeks to reduce the negative consequences that alcohol abuse has on individuals and their families. A key informant had this to say:

The new Policy [National Alcohol Policy], which the Ministry of Health (MOH) and the WHO unveiled, will encourage and promote abstinence [from alcohol consumption], lessen hazardous alcohol consumption, adhere to best practices around the world, and urge the government to take the lead in guaranteeing full compliance. (KII 2).

The FGDs with parents revealed that regulating the sale and consumption of alcohol by children in rural areas of the country is problematic. Parents in the Western and Eastern regions claimed that because the law prohibiting the sale of alcohol to minors is not strictly enforced, rural areas have a higher prevalence of underage drinking than urban areas. The use of alcohol by young people, especially children, has also been linked to disrespect, criminal activity, and other aberrant behaviors, according to parents. One parent explained:

Many of the children around here are alcoholics. They drink and misbehave in their homes and on the streets, and when adults dare to object, they will be beaten up or insulted. Due to their alcoholism, many parents no longer have complete control over their children in the community. (FGD 7).

FGDs with children confirmed that children consumed local alcoholic beverages, including palm wine and “Akpeteshie” (a popular locally produced alcoholic beverage in Ghana). Children often purchase alcoholic beverages from neighborhood bars, especially in rural areas, and bars in rural areas have no limitations on selling alcoholic beverages to children compared to urban areas. One key informant expressed:

All the drinking bars allow children to enter freely and purchase alcohol. Who they sell to is irrelevant to the bar owners. Their sole focus is on increasing sales. They refuse to heed the summons, despite the complaints of their parents and elders. (FGD 20).

4. Discussion

This study aimed to examine children lifetime prevalence of alcohol consumption and their reasons for alcohol consumption. The study also investigated predictors of children lifetime alcohol use and the effects of alcohol consumption on children. It furthermore examined the effectiveness of policies in place for regulating alcohol sale and use among children in Ghana.

The study found that children lifetime prevalence of alcohol consumption was 6.6%. Children lifetime prevalence of alcohol consumption in this study is lower than prevalence found previous studies from Ghana [ 7 – 9 , 18 ], Nigeria [ 19 , 21 ], and Iran [ 30 ]. For instance, Roshanfekr et al.'s [ 30 ] study among street children in Iran found that 16.6% had ever consumed alcohol. In Ghana, a study by Hormenu et al. [ 7 ] among in-school adolescents found that 42.3% of adolescents had ever consumed alcohol. The discrepancies in the prevalence of alcohol consumption could be attributed to varied factors, including differences in the sample population, measurement of alcohol consumption, and the studies not covering the whole country. For instance, previous studies on alcohol consumption among children in Ghana focused on selected regions in Ghana, namely, Central [ 7 ], Eastern [ 8 ], and Bono East [ 18 ] regions, than the entire country. Also, Alex-Hart et al.'s [ 19 ] study was among secondary school students, while Roshanfekr et al.'s [ 30 ] study was among street children. In terms of measurement of alcohol consumption, Hormenu et al.'s [ 7 ] study in Ghana measured alcohol consumption among in-school adolescents using how old respondents were when they had their first alcoholic drink.

The study also found that males are more likely to have ever consumed alcohol than females. This finding supports the first hypothesis that males are more likely to have ever consumed alcohol than females. The finding is consistent with prior studies [ 9 , 19 , 21 ], showing that alcohol consumption is more prevalent among males than females. Cultural expectations of masculinity may explain the high prevalence of alcohol consumption among males [ 5 , 31 , 32 ]. Culturally, alcohol consumption is acceptable for men but disapproved of for women [ 5 ]. However, this finding contrasts with previous studies in Ghana [ 8 ] and the United States [ 20 ], which found a high prevalence of alcohol consumption among females than males.

Regarding the age of children, our study found that there is a positive association between alcohol consumption and children's age. Thus, children aged 14–17 years are more susceptible to alcohol consumption than children aged 8–10 years. This finding confirms the second hypothesis that older children are more likely to have ever consumed alcohol than younger children. This finding corroborates earlier studies which found that alcohol consumption increases with age [ 2 , 9 , 22 ]. For example, a study by Aboagye et al. [ 23 ] among Ghana's tertiary students found a positive relationship between alcohol consumption and the age of students. Similarly, a study by Hormenu et al. [ 7 ] among in-school adolescents found that older adolescents (14-15 years) consumed more alcohol than younger adolescents (12-13 years). A plausible explanation is that as children grow, they are increasingly exposed to advertisements on alcoholic beverages, which may entice them to consume them.

The results also indicated that 1.4% of children aged between 8 and 10 had ever consumed alcohol. Zucker et al.'s [ 33 ] study found that early alcohol usage (before the age of 12) is linked with an increased risk of developing alcohol-related challenges during adulthood. Dunn and Goldman's study [ 34 ] highlighted that children's negative perceptions of alcohol and its effects change as they age. Older children, by extrapolation, have a higher alcohol consumption urge than younger children. This points to the importance of early interventions to discourage the early initiation of alcohol to forestall the development of alcohol-related challenges in later life.

Regarding the region of children's residence, the findings indicate that children from the Eastern and Northern regions are significantly less likely to have ever consumed alcohol than children from the Greater Accra region. A plausible explanation is that the Greater Accra region, which has Accra, the capital of Ghana, is often the epicentre of programs and advertisements on alcoholic beverages. The exposure of children in Greater Accra to programs and advertisements on alcoholic beverages may explain why they are more likely to have ever consumed alcohol. Studies have linked increased advertisements on alcoholic beverages with increased consumption of alcohol [ 35 – 37 ].

Our results also highlighted that more than half of children (53.5%) were influenced by friends to initiate alcohol consumption. This result corroborates other studies which found peer influence as a major predictor of alcohol consumption among children [ 38 – 40 ]. Proximately 17% of children were influenced by their older family members to initiate alcohol consumption, which supports the findings of earlier studies [ 5 , 31 ]. Our result also showed that 17% of children consumed their first alcohol at social gatherings, corroborating previous research findings [ 41 ]. Twelve percent of children had their first alcoholic beverages at drinking bars, and this phenomenon is more prevalent in rural areas [ 42 , 43 ]. This result is not unexpected given the wide variety of drinking bars/pubs in Ghana [ 44 ], and it is common for adults and parents to send children to purchase alcoholic beverages at these drinking places [ 45 ].

In addition, this study found that alcohol consumption was part of children's group culture, corroborating previous studies which found peer group influence as a significant determinant of children attitudes and actions [ 38 ]. When some members of a group consume alcohol, it is possible other members may be influenced to initiate alcohol consumption due to group culture.

Some children were motivated to consume alcoholic beverages to boost their confidence (21.6%), whet their appetite for meals (18.6%), and as a medication for the treatment of their ailments (15.0%). This finding is unsurprising since advertisements on alcoholic beverages highlight these attributes, influencing children to consume alcohol [ 46 ]. Studies have also documented the use of alcohol in preparing herbal medications to treat ailments [ 47 , 48 ].

Furthermore, 7.5% of children reported that drinking alcohol was a ritual in their groups or homes, supporting other studies [ 41 ]. Also, 5.1% of children reported consuming alcohol to forget their worries. This finding supports previous studies, which found that adults sometimes consume alcohol to forget about problems/issues [ 49 – 51 ]. This finding highlights the need for health practitioners and policymakers to educate children on active coping strategies for their daily challenges.

Respondents mentioned varied effects of alcohol consumption, including negative impacts on academic achievement, involvement in delinquent behavior, occurrences of accidents and fatalities, enhanced self-assurance, forgetting challenges, and heightened susceptibility to contracting diseases. Despite children being knowledgeable about the negative effects of alcohol consumption, there is a need to strengthen public education on alcohol consumption to reduce the prevalence of children's alcohol consumption.

Our results highlighted the availability of regulations, policies, and state agencies to regulate children's alcohol consumption and its effects. Despite these measures (legislations, policies, and state agencies), the sale of alcoholic beverages to children and children alcohol consumption is a common phenomenon. Also, there is a weak enforcement of regulations on selling alcoholic beverages to children in rural areas, making those children more susceptible to consuming alcohol. This finding is similar to a study by Senya and Floyd [ 52 ] in Ghana, which found that most sellers of alcoholic beverages (85%) were willing to sell alcohol to children to increase their sales, although they were aware it was unlawful.

Furthermore, alcohol intoxication made children in rural areas to exhibit negative behavioral outcomes, including disrespect, violence, rebellion, and disregard for the law. This result supports other studies which reported alcohol-related problems, including rebellion [ 53 ], violence [ 54 ], unruliness, and disrespect for authority [ 55 , 56 ]. Inferring from the results, children who reside in rural areas are a vulnerable population to indulge in underage alcohol consumption. Hence, policymakers and researchers need to focus on this population to better understand their needs to enhance their health and general wellbeing due to the adverse effects of underage alcohol consumption on children. In addition, policymakers should ensure the enforcement of regulations on alcohol sales and use among children, especially in rural areas. In addition, organizations mandated to deal with the menace of underage alcohol consumption in the country should strengthen their efforts in public education regarding the adverse consequences of alcohol consumption on children and the general population.

5. Limitations

This study has some limitations. Children were inquired regarding their history of alcohol consumption. Due to the perception of underage alcohol consumption as deviant and illegal for individuals below the age of 18, there is a likelihood that children may provide inaccurate or incomplete accounts of their involvement in such activities. Also, the study was cross-sectional. Hence, causality cannot be established. Third, studies have identified vital variables that predict alcohol consumption, including peer and parental use of alcohol, household wealth quintile, and academic adjustment problems [ 16 – 18 , 23 ]. However, these variables were not included in the binary logistic regression since they were unavailable in the dataset. Despite these limitations, the findings of this nationally represented study deepen health practitioners' and policymakers' understanding of children's alcohol consumption in Ghana, which will aid in designing appropriate interventions to curb the phenomenon.

6. Conclusions

Our results showed that children lifetime alcohol consumption was less than one-tenth (6.6%). Lifetime alcohol consumption was prevalent among older children (14–17 years), children with senior high school education, and males. Again, friends were a major determinant of alcohol consumption among children. Most children got drunk after consuming alcohol, and boosting confidence was the main facilitator of alcohol consumption among children. The findings of the study demonstrated that the government's efforts to stop the sale and consumption of alcohol by children have been ineffective.

Furthermore, the sex of children, age of children, and region of residence were significant predictors of alcohol consumption among children aged between 8 and 17. Policymakers should target these characteristics when developing interventions to reduce alcohol consumption among children.

Acknowledgments

We appreciate the Ministry of Gender, Children and Social Protection (MoGCSP) allowing us access to the data. We also want to express our gratitude to all the children participating in this research. We are grateful to Research Square for hosting an earlier version of this manuscript as a preprint on their platform.

Data Availability

This manuscript was earlier submitted as a preprint to the Research Square [ 57 ].

Conflicts of Interest

The authors declare that there are no conflicts of interest.

Authors' Contributions

This study was conceived and designed by SK-G and FK-A. The data processing and analysis were conducted by SK-G and FK-A. The manuscript was prepared by SK-G, NW, and FK-A. All authors contributed to the editing and final approval of the manuscript for submission.

Social ecological factors affecting substance abuse in Ghana (West Africa) using photovoice

Ahmed Kabore, Evans Afriyie-Gyawu, James Awuah, Andrew Hansen, Ashley Walker, Melissa Hester, Moussa Aziz WonadÃ© SiÃ©, Jarrett Johnson, Nicolas Meda

Received: 24 May 2017 - Accepted: 09 Dec 2019 - Published: 30 Dec 2019

Domain : Community health,Global health,Health education

Keywords : Substance abuse, illicit drugs, drug addiction, mental health, risk factors, protective factors, West Africa

© Ahmed Kabore et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Ahmed Kabore et al. Social ecological factors affecting substance abuse in Ghana (West Africa) using photovoice. Pan African Medical Journal. 2019;34:214. [ doi : 10.11604/pamj.2019.34.214.12851 ]

Available online at: https://www.panafrican-med-journal.com//content/article/34/214/full

Ahmed Kabore 1,2,3,& , Evans Afriyie-Gyawu 1 , James Awuah 4 , Andrew Hansen 1 , Ashley Walker 1 , Melissa Hester 1 , Moussa Aziz Wonadé Sié 2 , Jarrett Johnson 1 , Nicolas Meda 2,3

1 Jiann-Ping Hsu College of Public Health, Statesboro, Georgia Southern University, Georgia, United States, 2 Centre Muraz, Department of Public Health, Bobo-Dioulasso, Burkina Faso, 3 Joseph Ki-Zerbo University, Department of Public Health, Ouagadougou, Burkina Faso, 4 University of South Dakota, Sanford School of Health Sciences, South Dakota, United States

& Corresponding author Ahmed Kabore, Joseph Ki-Zerbo University, Department of Public Health, Ouagadougou, Burkina Faso

Introduction: substance abuse is an important public health issue affecting West Africa; however, there is currently a dearth of literature on the actions needed to address it. The aim of this study was to assess the risks and protective factors of substance abuse in Ghana, West Africa, using the photovoice method.

Methods: this study recruited and trained 10 participants in recovery from substance abuse and undergoing treatment in the greater Accra region of Ghana on the photovoice methodology. Each participant received a disposable camera to take pictures that represented the risk and protective factors pertinent to substance abuse in their communities. They were also given the opportunity to provide narratives of the pictures using pre-identified themes and the different levels of the social-ecological model and participatory action research (PAR).

Results: participants identified at the individual level: ignorance; interpersonal level: family and peer pressure; organizational level: lack of regulation; community level: media, availability of drugs, cost of drugs, urbanization, slum communities and cultural factors; and policy level: lack of regulations and their enforcement. Education and beliefs were cited at the individual level; family at the interpersonal level; religion at the organizational level; organizing youth, media and narcotics anonymous at the community level; and nothing at the policy level.

Conclusion: this is an exploratory study that will add to the limited body of knowledge in the scientific literature with respect to substance abuse in the country and also help develop interventions to address the respective needs of several communities in Ghana.

Drug abuse continues to be a controversial issue around the globe. It leads to enormous loss in life, and its effects spill over into the general society as well, thereby hindering the effective functionality and growth of populations [ 1 ]. In developing countries, for instance, the harm is magnified by the poor economic and living conditions. Government spending on substance abuse treatment is seen as an extra financial burden on an already strained budget. Furthermore, drug addiction can threaten civic safety, given that people under the influence of drugs may have a distorted view of the world around them and are prone to participating in improper behaviors such as armed robbery, traffic violations, and domestic violence [ 2 ]. Such persons can then become a danger to their family, the general public, and the environment [ 3 ]. Substance abuse also increases the risk of spreading infectious diseases such as HIV/AIDS, hepatitis B and C and tuberculosis. Drug abusers tend to share infected needles and cannot make appropriate decisions while under the influence of controlled substances, which can lead to the spread of the above-mentioned infections. Additionally, being under the influence of illicit drugs can also increase the incidence of unprotected sex [ 4 ]. Studies on substance abuse and potential intervention strategies in Africa are extremely limited in the scientific literature, highlighting the need for more research on this subject. Thus, the primary objective of this study was to assess the risk and protective factors pertinent to substance abuse in Ghana, West Africa, using the photovoice methodology.

This current study sought to explore the risk factors regarding substance abuse in Ghana, West Africa. Overall, the participants could identify why people use or abuse drugs from different perspectives, including ignorance at the individual level; family and peer pressure at the interpersonal level; lack of regulation at the organizational level; the availability of drugs, the cost of drugs, the media, urbanization, and slum communities at the community level; and lack of (or inadequate) enforcement and regulations at the policy level. The participants also identified potential protective factors against substance abuse in their communities. As described by participants, drug addiction is not viewed as a disease in Ghana, which makes it difficult to develop interventions. Addiction-related issues receive less attention from the population and at the policy level. Further studies are warranted to help educate the population about the dangers of drugs that are easily accessed on the streets of Ghana. Prevention remains the best option for addressing this issue of substance abuse because of the wide range of available treatment processes.

What is known about this topic

Literature has addressed the fact that substance abuse was a concern in West Africa;
Literature has addressed the challenges of addressing the issue in the region.

What this study adds

Youth in slum communities sell drugs in order to survive which makes drugs such as marijuana and amphetamine available and at low cost;
Education was highlighted as the most effective way to reach communities;
The Church and Mosques were chosen as the most effective avenue to educate communities about the danger of substance abuse.

The authors declare no competing interests.

All the authors have read and agreed to the final manuscript.

Table 1 : quotes based on the socio-ecological model Table 2 : risk factors to substance abuse according to participants in recovery Table 3 : protective factors to substance abuse according to participants in recovery Table 4 : action plan proposed by participants to reduce the risk of substance abuse in the community Figure 1 : a photo of shanty towns in Accra illustrates the canal of drug addiction; the slums spread over 5km and the only business they do there is selling drugs Figure 2 : a canoe at the seashore: canoes are used to transport the drugs that come from South America from the high seas to the seashore, with canoes, it is easy to bring the drugs into Accra, Ghana Figure 3 : a photo of a church in Accra illustrates the role of religious groups in the fight against substance abuse in Ghana Figure 4 : an open football field illustrates that youths in Ghana do not need much to practice a sport

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This article authors

Ahmed Kabore
Evans Afriyie-Gyawu
James Awuah
Andrew Hansen
Ashley Walker
Melissa Hester
Jarrett Johnson
Nicolas Meda

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Published: 16 November 2023

Assessment of prevalence, predictors, reasons and regulations of substance smoking among children in Ghana

Sylvester Kyei-Gyamfi 1 &
Frank Kyei-Arthur 2

BMC Public Health volume 23 , Article number: 2262 ( 2023 ) Cite this article

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In Ghana, it is against the law for children to smoke. Nevertheless, a portion of children in the country do smoke. However, there is a paucity of research on young smokers in Ghana and other sub-Saharan African nations. This study, therefore, investigated the prevalence of smoking, the kinds of substances children smoke, predictors of smoking, reasons for and factors that lead children to smoke, and regulation of smoking among children in Ghana.

In total, 5024 children aged 8–17 were studied using a cross-sectional convergent parallel mixed method. Descriptive statistics, Person’s Chi-square test, Fisher Exact test, and binary logistic regression were used to analyse the quantitative data. In contrast, thematic analysis was used to analyse the qualitative data.

The results showed that 3.2% of children had ever smoked. Male children smoked more often than female children. The prevalence of cigarette, marijuana, and shisha smoking was 78.3%, 18%, and 3.7%, respectively. While more male children than female children smoked cigarettes and marijuana, more female children than male children used shisha. Children mainly smoked for fun and due to group culture. In addition, children were influenced by friends; parents, family members, and neighbours who smoke; curiosity; and advertisements and videos to initiate smoking. Despite the availability of regulations and laws regulating tobacco products in public places, tobacco advertisement, promotion, and sale to persons under 18, children are still smoking.

Conclusions

Children who have ever engaged in smoking reported using cigarettes, marijuana, and shisha. Policymakers urgently need to strategise and strengthen their policies, programmes, and interventions to address smoking among children.

Peer Review reports

Smoking among people under 18 is increasingly becoming a public health concern in Ghana. The laws of Ghana prohibit smoking among persons under 18, yet there is evidence of children smoking. The Tobacco Control Regulations 2016 (L. I. 2247) and the Public Health Act 2012 (Act 851) are some laws that seek to prohibit and regulate the sale of tobacco substances to persons under 18. Despite these laws, the 2016 Multiple Indicator Cluster Survey (MICS) [ 1 ] indicates that 1% of adolescent girls and 6% of adolescent boys aged 15–19 have ever used tobacco. The Ministry of Gender, Children and Social Protection (MoGCSP) also reports that some children in Senior High Schools smoke marijuana, and about 90% of cases at the Accra Psychiatric Hospital annually, are drug abuse related among young people [ 2 ].

In Ghana, studies have documented that children engage in shisha/waterpipe, cigarette, and marijuana smoking [ 3 , 4 , 5 ]. For instance, Asante et al.‘s [ 4 ] study found that the prevalence of the use of marijuana among young people aged 11–19 years was 5.3%. Logo et al.‘s [ 5 ] study using nationally representative data on Junior High School students in Ghana found that 3.1% of students had ever smoked shisha/waterpipe. In comparison, Amonoo-Lartson and Pappoe’s [ 3 ] study among students in Senior High School found that the prevalence of smoking only cigarettes, only marijuana, and both cigarettes and marijuana were 5.3%, 0.6%, and 5.2%, respectively.

Although the prevalence of tobacco use among children in Ghana is low, it is still worrying since it is illegal and has dire consequences for their safety and health. Studies have linked substance smoking to an increased risk of premature deaths, disabilities, bad breath, respiratory diseases, sleep-related impairments, and non-communicable diseases among smokers [ 6 , 7 , 8 , 9 ].

Since early smoking initiation negatively impacts health, measures to reduce smoking among children and adolescents are vital [ 10 ]. However, a few nationally representative studies have been conducted on smoking among children in Ghana [ 1 , 4 , 5 , 11 ]. Effective smoking prevention measures require an in-depth understanding of children’s smoking experiences. The current study, which used nationally representative data, is of utmost significance since it will enhance policymakers’ understanding of children’s smoking experiences to further strategise national programmes, policies, and interventions to reduce its prevalence among children. The study aimed to investigate the prevalence of smoking, the kinds of substances children smoke, and predictors of smoking in Ghana. It also examined the reasons for and factors that lead children to smoke and the regulation of smoking among children in Ghana.

Study design and sampling procedure

This study used a convergent parallel mixed-method design. A convergent parallel mixed-method design is a type of mixed-method in which the researcher concomitantly collects quantitative and qualitative data to compare, relate or validate findings [ 12 ]. The researchers in this study used a multi-stage sampling strategy. Twenty percent (20%) of districts throughout all ten regions of Ghana were randomly selected based on child protection criteria. Of 216 districts across the country, 43 districts were randomly selected. In each of the 43 districts, 15 enumeration areas (EAs) were randomly selected for enumeration. In total, 645 EAs were randomly selected. Third, 8 children aged 8–17 in households were randomly selected in each EA. In households with two or more children aged 8–17, the youngest child was selected. In total, 5,160 children aged 8–17 were eligible to be interviewed. Out of the 5,160 children aged 8–17 who were eligible to be interviewed, 5,024 children were randomly selected to participate in the study. In total, 5,024 children aged 8–17 were interviewed using a semi-structured questionnaire for the quantitative data.

For the qualitative data collection, a focus group discussion (FGD) was conducted with children aged 8–17 in each of Ghana’s ten regions to explore children’s substance smoking behaviours, including the types of substances children smoke, the reasons why children smoke, and locations where children smoke. The FGDs were conducted in Akwamufie, Nkran - Nkwanta, Elmina, Atimpoku, Agyei-Kojo, Yendi, Gongnia, Jirapa, Nkonya, and Huni-Valley. In total, ten FGDs were conducted with children aged 8–17, and the discussions were conducted in town halls in the ten communities. Each FGD had between 8 and 10 participants. In total, 92 participants participated in the ten FGDs. In terms of age, 32 participants were aged 14–17, while 30 participants each were aged 8–10 and 11–13. Three trained research assistants conducted the FGDs in each community. One trained research assistant was the moderator, while the remaining two trained research assistants were the notetakers. All FGDs were audio-recorded. The FGDs were conducted in English and local languages convenient for participants. The local languages included Twi, Fante, Ga, Ewe, Kasem, Gruni, and Dagbani.

In addition, 50 key informant interviews were conducted with staff of selected District Assemblies and state agencies that regulate substance use in the country and those that protect and promote the wellbeing of children. The staff of state agencies interviewed included the Department of Children (DOC), MoGCSP; Narcotics Control Board (NACOB); and Food and Drugs Authority (FDA).

Study setting

Ghana is located in West Africa, and it is bounded by Burkina Faso to the North, the Gulf of Guinea to the South, Togo to the East, and Côte d’Ivoire to the West. During the data collection in April-September 2018, Ghana had ten regions. However, following a referendum in December 2018, Ghana now has 16 regions. According to the Ghana Statistical Service, 30.8 people were residing in Ghana as of 2021 [ 13 ].

Description and conceptualisation of variables

Dependent variable.

The dependent variable for this study was whether children had ever smoked any substance, and the responses were Yes and No. Previous studies on smoking [ 3 , 14 ] guided the development of questions on smoking in the questionnaire (See Section L 12–16 of the supplementary file).

Independent variables

The independent variables for this study included sex (male and female), age (8–10 years, 11–13 years, and 14–17 years), educational attainment (not in school, primary, Junior High School (JHS), Senior High School (SHS) and Tertiary), religion (Christianity, Islam, and other), ecological zone (Coastal, Middle belt, and Northern zones), living arrangements (Both Biological Parents, Biological Mother Alone, Biological Father Alone, and Other), and currently working (Yes and No).

Data collection

This research is a subset of a larger project analysing the living conditions of children in Ghana. The larger project covered varied topics, including children’s rights, access to quality healthcare, sexual and reproductive health education, and internet and social media use (See supplementary file). This study focused on smoking among children. The data were collected between April and September 2018. The quantitative data were collected from children aged 8–17, while the qualitative data were collected from key informants and children aged 8–17.

Participation in the study was voluntary; all participants gave their written consent before their data were collected. For children aged 8–17, their parents and guardians gave their written consent before they were invited to participate in the study. The study was approved by the Institutional Review Board of the Department of Children, Ministry of Gender, Children and Social Protection (MoGCSP). The principles of the Helsinki Declaration were also followed during the data collection, and participants’ data were anonymised to protect their privacy.

Data analysis

The Statistical Package for Social Sciences (SPSS) version 26 was used to analyse the quantitative data. Descriptive statistics, such as frequencies and percentages, were used to describe the socio-demographic characteristics of participants and the prevalence of ever smoking. Associations between ever smoking and socio-demographic characteristics (sex, age, educational attainment, religion, ecological zone, living arrangement, and currently working) were examined using Person’s Chi-square test. Also, Fisher Exact test was used to test the association between ever smoking and educational attainment since a category of educational attainment had a cell count of less than 5. Binary logistic regression was used to determine predictors of smoking among children. Binary logistic regression was used because the dependent variable (whether children had ever smoked) had dichotomous outcomes (Yes and No). All associations between variables are statistically significant at a 95% confidence interval (P < 0.05).

The qualitative data was analysed thematically. All participants’ transcripts were read to get a general sense of the smoking experiences of children aged 8–17. Perceptions of participants that aligned with the objectives of the study were assigned unique codes. Similar unique codes were merged into sub-themes. Sub-themes related to similar issues were integrated into themes.

Socio-demographic characteristics of participants

The socio-demographic characteristics of the 5,024 sampled children aged 8–17 are presented in Table 1 . According to Table 1 , a little over half (51.1%) of the children interviewed were males. Most children (75.1%) were Christians, while 21.6% were Muslims. The age breakdown of the children shows that a larger proportion (43.7%) were between the ages of 14 and 17.

In terms of education, 42.1% were in primary school, 31.5% were in JHS, 23.5% were in SHS, a little over 2% were in tertiary institutions, and less than 1% had no formal education. The number of children sampled was highest in the Middle belt (40.7%) and lowest in the Northern zone (23.4%). Regarding living arrangements, most children (58.4%) lived with their biological parents, while about 5% lived with their biological father. The majority of children (96%) were not currently working.

Prevalence of ever smoked

In this study, 3.2% of the children sampled reported they had ever smoked, with more males (5.5%) than females (0.8%) doing so (Table 2 ). The percentage of children who had ever smoked was significantly associated with age (p-value = < 0.001), with children aged 14–17 having the highest rate, followed by those aged 11–13 (1.0%) and 8–10 (0.8%). Also, participants’ educational attainment was significantly associated with children ever smoked (p-value = < 0.001), with the reported smoking habit being highest among SHS children and least among children who had no formal education.

The highest prevalence of ever smoked was found among children who were Christians (14.2%), belonged to other religious categories (5.0%), and Muslims (4.4%). The association between children ever smoked, and religion was statistically significant (p-value = < 0.001). Children in the Coastal zone had the highest proportion (5.7%) of children who had ever smoked, while children from the Northern zone had the lowest proportion (1.1%). The association between children ever smoked and the ecological zone was statistically significant (p-value = < 0.001).

Furthermore, the percentage of children who had ever smoked was significantly associated with living arrangements (p-value = < 0.001), with children living with their biological father having the highest proportion (7.6%) of children who had ever smoked, while children living with their biological parents having the lowest proportion (2.6%). The highest prevalence of ever smoking was found among children currently working (12.0%). The association between children ever smoked and children currently working was statistically significant (p-value = < 0.001).

Kinds of substances children smoked

Table 3 presents the kind of substances children smoked. The results show that nearly eight out of ten children (78.3%) smoked cigarettes, 18% smoked marijuana, and 3.7% smoked shisha. Also, a higher proportion of male children smoked cigarettes (78.9%) and marijuana (18.3%) than female children (73.7% and 15.8%). However, more female children (10.5%) smoked shisha than male children (2.8%). In terms of frequency of smoking, most children (57.1%) smoked once, followed by those who smoked several times (32.3%). A higher proportion of male children (58.5%) smoked once than female children (47.4%), while a higher proportion of female children (36.8%) smoked several times than male children (31.7%).

Smoking of cigarette

The FGDs provided information on the kind of illicit substances children typically smoke. Most interactions in rural and urban settings demonstrated that cigarettes are the most popular tobacco product smoked by children in the country. Children frequently purchase cigarettes from adult peddlers in urban areas because they cannot purchase them from stores. A child reported that:

Most of the younger people who smoke in [Tema] Community 3, where I reside, are boys, and all smoke cigarettes. Children in Tema Township find it very challenging to purchase cigarettes in stores or bars since the laws prohibiting the sale of tobacco products to minors are strictly enforced. It is pretty difficult to purchase cigarettes unless you can find a “pusher” [peddler] and buy from him. (FGD 1)

However, some participants highlighted that there is poor enforcement of the sale of cigarettes in community bars in rural areas. They also mentioned that children sometimes use the excuse that their parents or uncles have sent them as a decoy to purchase cigarettes for themselves. A child in one of the FGDs in a rural area made the following statements:

In small towns like ours, cigarette vendors do not question children when they enter their stores or bars to make purchases, and even if they do, children explain that they are purchasing cigarettes for their parents, uncles, or other family members. This makes it easy for children to buy cigarettes. Since several children have smoking relatives, it can occasionally be challenging to tell if they are telling the truth. (FGD 2)

Smoking of marijuana

FGDs with children revealed that children smoke marijuana and often hide when smoking. Consequently, they indicated that it is difficult to estimate the proportion of children engaged in marijuana smoking. The quote below corroborates the theme:

A few children I know smoke “wee” [name of marijuana in the local language]. Children who smoke ‘wee’ often transitioned from smoking cigarettes for years to “wee” smoking. Since it is illegal to even for adults to smoke ‘wee,’ it is pretty challenging to know the magnitude of children engaged in ‘wee’ smoking in this area. However, it is common knowledge that some children smoke it. (FGD 3)

Smoking of waterpipe/shisha

A key informant revealed that girls are increasingly smoking waterpipe/shisha. He defined waterpipe/shisha as a smoking technique using one or more stemmed instruments to smoke flavour or unflavoured tobacco. He added that before the stemmed smoke reaches the smoker, it passes through water or other liquids. He elaborated that the primary cause of the increased patronage of waterpipe/shisha is the myth that the flavoured or unfavoured tobacco used in waterpipe/shisha and the water that the stemmed smoke passes through makes waterpipe/shisha smoking less risky than cigarette smoking.

Waterpipe/shisha was unknown in our part of the world until recently. But it has recently become popular among young people, including children, in the urban areas. Although smoking is uncommon among Ghanaian women, waterpipe/shisha use is more widespread among young urban females. This is due to the erroneous belief that shisha is less harmful than cigarettes and other illicit substances. (KII 1)

Predictors of smoking among children

Regarding educational attainment, not in school and primary school were merged since not in school had few cases. Table 4 presents the predictors of smoking among children. Children aged 8–10 (AOR = 0.178; 95% CI = 0.050–0.633; p-value = 0.008), children aged 11–13 (AOR = 0.253; 95% CI = 0.105–0.614; p-value = 0.002), children residing in the Middle belt (AOR = 0.361; 95% CI = 0.248–0.526; p-value = < 0.001), and children residing in the Northern zone (AOR = 0.153; 95% CI = 0.081–0.291; p-value = < 0.001) were less likely to have ever smoked.

Also, male children (AOR = 8.819; 95% CI = 5.373–14.475; p-value = < 0.001) and children living with their biological fathers (AOR = 1.850; 95% CI = 1.022–3.347; p-value = 0.042) were more likely to have ever smoked.

Reasons for and factors that lead children to smoke

Children aged 8–17 were asked to give the reasons why children engage in smoking. From Table 5 , a little over two-fifth (41.6%) of participants reported they smoked for fun, while two fifth (40.4%) of participants smoked due to group culture. About one-tenth (9.9%) of participants smoked to get ‘high,‘ while about 6% smoked to relieve boredom or anxiety. Furthermore, about 2% of participants smoked out of curiosity.

The study also examined the factors that lead children to smoke. Table 5 shows that over half (57.3%) of participants reported that their friends influenced them to smoke. In comparison, a little over one-fifth (21.7%) of participants were influenced by family members who smoke to initiate smoking. A little over one-fifth (12.7%) of participants were influenced by curiosity to smoke, while less than one-fifth (8.3%) were motivated by advertisements and videos on smoking to initiate smoking.

During the focus group discussions, children aged 8–17 were also asked to provide their thoughts on what they considered were the main drivers influencing children to initiate smoking cigarettes and other tobacco products. The children mentioned that the main drivers of smoking among children were having friends, parents, other family members, or neighbours who smoked. For most participants having friends who smoke has a compelling influence in making them cultivate the habit of smoking. This finding supports the quantitative data that having a friend who smokes influences children to initiate smoking. Below are the views of participants:

Most children belong to groups. They join groups at school, and they also have friends in their neighbourhoods. If a child or a member of the group smoke, they may persuade other members to try smoking. Once children start smoking, they may become addicted to it. (FGD 4)

Some children smoke to be accepted within their group of friends because of fear that their smoking friends won’t accept them [non-smoking members]. So for many children, smoking has become a means to be accepted and retain their group memberships. (FGD 5)

The FGDs also highlighted that having parents or other family members who smoke has a compelling influence in making a child stick to smoking as a habit. This finding is similar to quantitative findings that family members who smoke influence children to initiate smoking. One child explained that:

All the men in our home, including my father, uncle, and brothers, smoke. They usually send me to go out to buy their cigarettes. I occasionally take a couple when they send me or use my money to try it out for fun and to have a feel of it. (FGD 6)

Another child, whose uncle had introduced him to smoking, narrated the following:

I’m close with my younger uncle, and we get along well. He smokes a lot if I go with him somewhere. On one occasion, he offered me a cigarette in exchange for my pledge not to tell anyone. (FGD 7)

Where children smoke

According to the qualitative findings, children in Ghana do not openly smoke in public spaces. Participants in the FGDs said that many children who smoke pick covert locations since they know smoking is unacceptable. The FGDs show that areas such as deteriorating, unfinished, and abandoned buildings make up sites where children typically hide out to smoke. Others reported that some children smoke in the bushes, on beaches, dark places at night, and in bars. The following quotes by some participants in the FGDs corroborate the theme:

Smoking is common among children in this town, but they hide to do it at the beach. If you go there right now, you will see it for yourself. Some children from the surrounding SHS schools remove their uniforms and pretend they are ordinary children from the Edina community. (FGD 8)

Numerous reports of children smoking marijuana in the past few years have been made to the school administration. The school is quite concerned about this. Our Senior Housemaster, who is a disciplinarian, smart, and aware of some of the places where students hide to smoke, occasionally walks around the school’s campus, checking for anyone who might be smoking. His actions have led to a decrease in its occurrence, although some students continue to smoke in places where it is more difficult to monitor them. (FGD 9)

In the Komenda Edina Eguafo Abirem (KEEA) Municipality, a key informant reported that children who smoke marijuana are occasionally arrested during police swoops. He explained that:

The police occasionally make swoops to arrest persons who smoke ‘wee’ in various smoking hiding places. By chance, some of these individuals are very young, including children. They hide in bushes, abandoned buildings, and sometimes kiosks to smoke. There is a church building here, and it is in a secluded place. When church service is over, that is when young people, including children, go to smoke. The sad thing is that it includes a few girls. It’s really a bothersome development. (KII 2)

Regulation of smoking among children

KIIs with the staff of government agencies revealed that smoking among children is fast becoming a challenge despite regulations prohibiting the sale of cigarettes to persons under 18. They reported that the government is concerned, and through its agencies, it is taking measures to address it. A staff of DOC noted that smoking among children constitutes a vital subject/theme in their public outreach campaigns. The key informant narrated that:

Tobacco use among children also constitutes a grave concern for the country. We have received reports and believe some children in the Senior High School smoke marijuana, cigarettes, and shisha. It has also been reported that about 90% of cases at the Accra Psychiatric Hospital annually are drug abuse related, and most cases are young people, including children. These reports provide enough evidence to suggest that substance abuse is gaining ground in Ghana among the youth, including children, so we need to act quickly to salvage the situation. The NCCE, DOC, DSW, and their CSO partners may have to intensify their educational drive on substance abuse, which seems to be a rising trend among young people in the country. (KII 3)

Another key informant highlighted the need for the government to adequately resource them to help perform their responsibilities, which will help curb smoking among children.

Since smoking is not tolerated in Ghana, not even among adults, reports of children smoking are alarming. As a child related agency, we work closely with our law enforcement partners to encourage reporting and investigating any concerns about the possession and use of illegal substances so that the necessary action can be taken to stop youth smoking before it starts. We know it will be challenging, but we must nonetheless complete it. However, we shall implore the government to provide the necessary material and financial backing to fulfil our responsibilities properly. (KII 4)

Another key informant explained that shisha is prohibited in Ghana despite its usage among the general population, including children.

By law, the Food and Drugs Authority (FDA) must regulate the use of shisha. This requires operators to come to register before offering it to the public. To date, no one has come to us to register. This means anyone providing shisha to the public is engaged in illegality (KII 4) .

A key informant at the Narcotics Control Board (NACOB) indicated that the Narcotic Drugs (Control, Enforcement, and Sanctions) Law 1990 (PNDCL 236) bans narcotic drugs and establishes the NACOB to stem the flow of drugs into the country. The key informant also mentioned that Ghana has also signed and ratified many United Nations Conventions and Protocols on drugs, such as the 1961 Single Convention, 1971 Convention on Psychotropic Substances, 1972 Protocol Amending the 1961 Single Convention, and 1988 Convention against Illicit Trafficking of Narcotic Drugs and Psychotropic Substances. In line with UN guidelines, all signatories, including Ghana, must follow guidelines set out to tackle issues related to drug control and controlled substances that affect younger people, especially children. In effect, the use of psychotropic drugs is an area the government strives to fight not only among children but also among adults. An official at the Commission on Human Rights and Administrative Justice summed up the crucial steps taken by the government to confirm the narrative:

The Ghanaian government has made significant efforts to combat smoking among young people, including children. Legal measures, such as the passage of national laws and the ratification of international treaties, are some of the steps adopted to regulate the use of tobacco products among children in the country. The government has also implemented institutional strengthening, increased awareness-raising efforts across all regions, and developed child protection policies. (KII 5)

The study aimed to examine the prevalence of smoking, the kinds of substances children smoke, predictors of smoking, reasons for and factors that lead children to smoke, and regulation of smoking among children in Ghana. The findings indicate that 3.2% of children had ever smoked, and it is more prevalent among male children (5.5%) than female children (0.8%). On the one hand, the prevalence of smoking among children in this study was low compared to earlier studies in Serbia [ 15 ] and Malaysia [ 14 ]. For instance, Veres et al.‘s [ 15 ] in Serbia among high grade primary students found that 35% of students had ever smoked. Norbanee et al.‘ [ 14 ] study in Malaysia among primary school children found that 25% of children had ever smoked. On the other hand, the prevalence of smoking among children in this study was high compared to a study in Brazil [ 16 ]. Silva et al.‘s [ 16 ] study among children aged 7–17 in Brazil found that 2.4% of children had ever smoked. The differences in smoking prevalence among children could be attributed to differences in the sample population, respondents’ ages, and measurements. For instance, Silva et al.‘s [ 16 ], Norbanee et al.‘ [ 14 ], and Veres et al.‘s [ 15 ] studies were conducted among school going children, while this study was conducted among both school going and non-school-going children. Also, Veres et al.‘s [ 15 ] study was conducted among children aged 11–15, while Silva et al.‘s [ 16 ] and Norbanee et al.‘ [ 14 ] studies were conducted among children aged 7–17.

The study also found that male children reported higher smoking prevalence than female children. The multivariate analysis also showed that male children are more likely to have ever smoked. These findings are similar to those of earlier studies [ 1 , 17 , 18 ]. A plausible explanation is that males are more likely to engage in risky behaviour than females [ 19 , 20 ].

Furthermore, smoking was more prevalent among older children than younger children. The multivariate analysis also showed that children aged 8–10 and 11–13 were less likely to have ever smoked. This finding supports earlier studies that smoking is more prevalent in older children than younger children [ 14 , 16 ]. Older children may be more exposed to tobacco products and are, therefore, more likely to try smoking than younger children.

Children residing in the Coastal zone were more likely to have ever smoked than children living in the Middle belt and Northern zone. Greater Accra region is situated in the Coastal zone, and studies have found that the prevalence of smoking is highest in the region [ 1 , 11 ]. Therefore, the high prevalence of smoking in the Greater Accra region may explain why children in the Coastal zone are more likely to have ever smoked than children residing in other ecological zones.

According to the study, cigarette smoking (78.3%) is far more common among children in the country than marijuana or shisha usage (18% and 3.7%, respectively). This supports earlier findings by St Claire et al. [ 21 ], which found that cigarette smoking is the most popular smoking habit among children. The results also highlighted sex differentials in smoking, with cigarettes and marijuana smoking being more prevalent among male children, while shisha smoking was more prevalent among female children. Shisha smoking was more prevalent among female children because of the perception that it is less harmful compared to cigarettes and marijuana [ 22 ]. Females are often less likely to take risks than males [ 19 , 20 ].

The study also revealed that some children who used marijuana had a history of smoking cigarettes, supporting previous research that indicates an association between marijuana and cigarette use [ 23 ]. This finding suggests a connection between smoking cigarettes and switching to marijuana use.

Regarding the frequency of smoking, the majority of children (57.1%) had smoked once, 32.3% had smoked repeatedly, 5.6% were unable to recall how many times they had smoked, and 5% had smoked twice. Despite the low prevalence of smoking among children, it is worrisome that 32.3% had smoked repeatedly, and 5.6% could not recall how frequently they had smoked. Another concerning finding is that over 2 out of 10 children who had ever smoked also smoked marijuana. These findings urgently call for policy makers to strategise and strengthen their policies, programmes, and interventions to address smoking among children.

A little over four out of ten children smoked for fun and due to group culture. Children also occasionally smoked to get high, to kill boredom or to calm their nerves, or just out of curiosity. Also, children were influenced by friends; parents, family members, and neighbours who smoke; curiosity; and advertisements and videos to initiate smoking. These findings corroborate previous studies, which found that friends [ 14 , 15 , 17 , 24 ], parents, family members, and neighbours who smoke [ 14 , 15 ], curiosity [ 24 , 25 ], and advertisements [ 3 ] influenced people to initiate smoking. These findings highlight the need for parents, relatives, and neighbours who smoke to be mindful of their smoking habits since it negatively impacts children’s smoking habits. Also, parents and guardians need to show interest in who their children spend time with or associate with. Policy makers should enforce the Tobacco Control Regulations 2016 (L.I. 2247), which regulates the advertisement, promotion, and sponsorship of tobacco products.

The multivariate analysis also found that children who live with their biological fathers are more vulnerable to smoking than those living with both biological parents. The lack of proper supervision by fathers may explain this phenomenon.

The qualitative findings further show that some children started smoking because they used to run cigarette deliveries for their family members, which offered them a chance to try it out. This situation strengthens the case for enforcing the Tobacco Control Regulations 2016 (L. I. 2247) and the Public Health Act 2012 (Act 851), which prohibits the sale of cigarettes to persons under 18. This finding supports an earlier study, which found that access to substance smoking products, such as e-cigarettes, influence smoking [ 26 ].

The qualitative findings point to various locations where children prefer to smoke, and many are hidden from the general public. Children’s smoking areas include deteriorating, incomplete, and abandoned structures, as well as bushes, beaches, dark places at night, bars and places far from their residences. Most children smoke in secret locations since they know smoking is considered a deviant act in Ghana. This finding supports Glenstrup et al.‘s [ 27 ] study, which found that adolescents who smoke feel discomfort when their smoking behaviour is exposed, so they keep their smoking habits hidden from the public.

The government has made some progress in passing laws, ratifying international treaties, establishing entities, raising public awareness, and putting in place controls over the use and distribution of tobacco products, which is typically what most children in the country smoke. Smoking among children is still prevalent despite the preventive measures taken and the government prohibiting the sale and use of tobacco products among children. According to the findings, this is typically caused by the lack of funding for government organisations to monitor and regulate measures that deter children from smoking. Although Ghanaian law forbids children from purchasing tobacco products, inadequate regulatory procedures allow children to access marijuana and tobacco products through unlawful channels. Although there is some compliance among specific retailers in urban areas, many tobacco product vendors in rural areas continue to sell to children out of ignorance or a lack of regard for law and order [ 28 , 29 ].

Strengths and limitations of the study

The study had some strengths. Key among them is the large sample size, which was nationally representative. The study also had a high response rate among children in all ten regions. This study significantly advances the knowledge of smoking among children and the factors that contribute to it. The results might be helpful for programming, regulation, and strategy for the country and other sub-Saharan countries. Despite the strengths, the study also has some limitations. First, children were asked if they had ever smoked. Since smoking is deemed a deviant act and prohibited by Ghana’s law among persons below 18 years, children may under-report their smoking habits. Second, there may be recall bias since children were to recollect their smoking experience, which may result in underreporting of their smoking encounters. Third, this study is cross-sectional; therefore, causal relationships between the dependent and independent variables cannot be established. Fourth, the secondary data used for this study is 5 years old; therefore, the substance smoking behaviour of children in Ghana may have changed. Despite the data being 5 years old, this study is warranted since it is essential to understand the past magnitude of substance abuse among children to serve as a reference point for policymakers to measure the success of their interventions implemented over the years to curb substance smoking among children. Fifth, the study did not ask children about their use of e-cigarettes, heat-not-burn and smokeless tobacco products.

The study indicated that the prevalence of smoking was low among children aged 8–17. Despite the relatively low prevalence of smoking among children in Ghana, this issue remains a cause for concern due to its illegality and the severe implications it poses on the health and wellbeing of children. The study also found that children who have ever engaged in smoking reported using cigarettes, marijuana, and shisha. Children were influenced by parents, peers and neighbours to engage in smoking. This study points to the need for an enhanced educational effort to improve children’s awareness of the risks associated with adolescent smoking in school and other settings. To prevent future smoking addiction in children, educating them about the dangers of smoking while they are still young is essential. The National Commission for Civic Education, Ghana Education Service, Ministry of Gender, Children and Social Protection, and their allies must support this educational initiative.

Data Availability

The datasets generated and/or analysed during the current study are not publicly available due to them containing information that could compromise research participant privacy but are available from the corresponding author on reasonable request.

Abbreviations

Civil Society Organisation

Department of Children

Department of Social Work

Enumeration Areas

Food and Drugs Authority

Focus Group Discussions

Junior High School

Legislative Instrument

Multiple Indicator Cluster Survey

Ministry of Gender, Children and Social Protection

Narcotics Control Board

National Commission for Civil Education

National Child Protection Committee

Reference Category

Senior High School

Statistical Package for Social Sciences

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Acknowledgements

We thank MoGCSP for granting us access to the data. In addition, we thank our participants for making this study possible.

We did not receive any funding for this study.

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Sylvester Kyei-Gyamfi

Department of Environment and Public Health, University of Environment and Sustainable Development, Somanya, Ghana

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SK-G contributed to the conceptualisation of the study and the study design. All authors contributed to the analysis of the data. Also, all authors wrote the first draft of the manuscript. Finally, all the authors contributed to the editing of the manuscript, as well as reading and approving the final version submitted.

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The study was approved by the Institutional Review Board of the Department of Children, Ministry of Gender, Children and Social Protection (MoGCSP). Children aged 8 to 17 who agreed to participate in the study signed the written informed consent form; parents or legal guardians signed the written informed consent form of all children aged 8 to 17. The principles of the Helsinki Declaration were also followed during the data collection, and participants’ data were anonymised to protect their privacy.

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Kyei-Gyamfi, S., Kyei-Arthur, F. Assessment of prevalence, predictors, reasons and regulations of substance smoking among children in Ghana. BMC Public Health 23 , 2262 (2023). https://doi.org/10.1186/s12889-023-17187-1

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Conclusions

Data and sample

Study variables

Independent variables

Statistical analyses

Socio-demographic characteristics of respondents

Prevalence of substance use

Correlates of substance use

Where respondents get substance

(A) supplies from peers

(B) household members who use substances

(C) purchasing from drug stores

(D) purchasing from gangs

Reasons for substance use

(A) substance use is fun

(B) use of substances as an aphrodisiac

(C) boosts confidence to approach the opposite sex

(D) forgetting anxieties

(E) substance use makes one popular and being perceived as the finest

Limitations

Data availability

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Electronic supplementary material

Working status of adolescents by sex.

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Substance Abuse Treatment, Prevention, and Policy

Where is the pain? A qualitative analysis of Ghana’s opioid (tramadol) ‘crisis’ and youth perspectives

1. Introduction

1.1 Tramadol in Ghana

2. Theoretical orientations

3. Methods of the study

Study design

Reflexivity

4. Findings and discussion

4.1 The condition of ‘youth’ and youth futures

4.2 Tramadol consumption as individual moral failure among youth

4.3 Pain as a fundamental reason for tramadol use

4.4 Beyond pain

5. Conclusion

Supporting information

S1 Table. Combined analysis and codes.

S1 Text. Interview questions.

S2 Text. Inclusivity in global research.

Acknowledgments

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Drugs and the Youth Ghana's Drug Policies in a Changing World

Drugs and the Youth Ghana's Drug Policies in a Changing World

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Prevalence, Reasons, Predictors, Perceived Effects, and Regulation of Alcohol Use among Children in Ghana

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