Teachers participating in this study adhered to the science curriculum and covered alcohol-related topics in class. They concentrated on four principal facets of alcohol education: production of alcohol, reasons for taking alcohol, effects of alcohol, and how to avoid it. Two predominant strategies were used to deter children from alcohol use, namely, the avoidance of places and peers that consumed alcohol as well as the danger-focused rhetoric aiming to provide knowledge about the dangers of alcohol and create negative attitudes towards it.
Avoidance of alcohol.
Science teachers followed the universal educational curriculum on alcohol use for 6th graders and among them they employed similar methods of teaching children about alcohol use. The effectiveness of school-based alcohol programs varies: most interventions increase knowledge and change attitudes towards alcohol but demonstrate limited impact on actual drinking behavior (36–39). Alcohol education through classroom curriculum is a widely used approach to educate learners about alcohol and to prevent alcohol use (40). However, there is little research on the delivery and the effectiveness of the Ugadan primary school alcohol education curriculum and overall, few school-based alcohol interventions have been conducted and assessed in Africa (25, 39). Alcohol use is a complex issue where personal characteristics and the environment influence person’s beliefs, attitudes, and behaviour towards alcohol (9, 38, 41). Although no definitive approach has been proven to lower alcohol use in different school settings, some educational approaches appear more effective compared to others.
Grube’s and Morgan’s theory suggests that a positive attitude towards alcohol is more likely to manifest if the environment supports it (42). Schools are a key source of alcohol knowledge and can shape learners attitudes towards substance use (43). As such, school can have both a conducive and a deterring role with respect to child alcohol use. The participating teachers in this study aimed to project a clear value of “zero tolerance” to alcohol and focused on creating a disapproving environment by teaching the disadvantages and negative aspects of drinking and by encouraging children to avoid alcohol. Teachers’ disapproving attitude towards alcohol use was also underlined by verbal or physical punishment of children who consumed alcohol. There is merit to suggest that this approach, to categorically adopt a disapproving position against alcohol and alcohol users, could limit substance use by the learners (44, 45). Some studies indicate that zero tolerance approach to alcohol may delay alcohol use initiation thus reducing alcohol related harm, however, once alcohol use becomes more prevalent during adolescents the abstinence messaging becomes less effective and should be supplemented by harm minimization approaches (46, 47). Harm reduction programs focus on minimizing the severe consequences of alcohol use, and regard circumstances in which alcohol is consumed to be the main culprit of severe outcomes of alcohol use (48, 49) Furthermore, other studies suggest that zero tolerance interventions are unsuccessful in limiting alcohol consumption and may even increase alcohol use during adolescence (50, 51). Adolescents are often more skeptical to institutional control and have higher tendencies to rebel, thus being more likely to challenge societal norms and rules including alcohol use (50, 52). Although, some abstinent adolescents attribute their attitude to the zero-tolerance approach, the effect of this type of rhetoric may be limited to those individuals who are inherently less likely to initiate alcohol use due to their personal predisposition (53).
The setting of our study poses an additional challenge to the teachers’ zero-tolerance approach. Both teachers and learners reported that alcohol was readily available, consumed in the community, and difficult to avoid. Previous studies also indicate that children were exposed to daily alcohol use by their parents, the community, and through commercials (6, 8, 11). Alcohol can be served in proximity of schools and at times free sampling can be offered to children (6, 11). Considering the wide availability of alcohol and school environments conductive to drinking, the zero tolerance- and alcohol avoidance-approaches appear incongruent with the daily reality seen and experienced by school-attending children in Eastern Uganda.
Avoidance of peers.
In this study participants attributed peer pressure as the main reason for initiation and consumption of alcohol. This is confirmed by a study from Ugandan schools that indicated peer influence as one of the main factors for alcohol and substance use in schools (54). Although, there is a common assumption linking peers to alcohol use the evidence is mixed regarding the causality between peer influence and substance use (55). Some studies suggest a causal relationship, while others propose that adolescents may seek out like-minded friends, after initiating substance use, or that behaviors evolve together within the friend group (16, 42, 55). Generally, most young people drink for enhanced enjoyment in social gatherings and these enhancement motives are associated with personality traits of sensation seeking and with low inhibitory control (56–58). Overall, “Say No!” programs targeting refusal skills and resistance to peer influence have shown little effect compared to programs that target social norms, passive social pressure and interpersonal skills (55).
Danger focused rhetoric
Universal alcohol curriculum should include several key elements: dispelling misconceptions of substance use, including prevalence and the positive and negative effects of alcohol, addressing children’s perceptions of the risks associated with substance use and providing life-skills on alcohol decision making (40). In this study, teachers emphasized teaching children the negative consequences of substance use. Consequently, learners showed extensive knowledge of the harmful effects of alcohol. Teachers reasoned that knowledge of these negative effects would prevent children from consuming alcohol. One study from Tanzania supports this notion indicating that fear of side effects was one of the reasons for abstaining from alcohol (57). Although teachers from our study focused on the severe biological, mental, and social consequences of harmful alcohol use, they also regarded these dangers to be realistic for their community. Similarly, studies report that Ugandan children face high rates of sexual and physical violence as well as homelessness, lack of basic needs and social support where alcohol use can be one of the contributing factors for these negative outcomes (6, 11, 59, 60). Thus, while the alcohol use dangers taught by the teachers were severe, they were also grounded in reality of Ugandan children.
However, the aim of teaching these negative effects of alcohol use was to scare children rather than provide them with factual and nuanced information of the negative effects of substance use. One review showed that in some instances scare tactics could be beneficial and reduce substance use, however, they pointed out that the methods used should not be moralizing, exaggerated or raise demands for zero substance use (61). Overall, focusing only on emotional education and fear arousal is considered ineffective alcohol use prevention method (40). The moralizing and didactic nature of zero tolerance and scare tactics may hinder open discussion on alcohol use. Furthermore, stigmatizing alcohol users as criminals and nuisance to society and labeling children as “spoiled” and troubled may alienate struggling learners and hinder them from seeking help. Additionally, since teachers focused most on the unacceptable uses of alcohol and had zero tolerance approach to drinking, less attention was given to addressing responsible alcohol use including alcohol use attitudes such as not pressuring other to drink and behavior, how much people drink and how often. We noticed that children had varying opinions on acceptable amounts and frequency of alcohol use and teachers provided little nuance on how much alcohol should be consumed for given effects to occur.
Our findings suggest that teachers regarded alcohol education as an important subject. Many teachers showed concern and great care for their learners and aimed to prevent alcohol use by children. However, the didactic and moralizing methods of teaching alcohol use are not supported by literature. Therefore, a disapproving school standard against alcohol use could be supplemented by a more pragmatic harm reduction approach that acknowledges the prevalence and availability of alcohol in Uganda. Although, from the health perspective zero alcohol consumption is optimal, moral abstinence education is ineffective(40, 61). Meanwhile, harm reduction programs have shown to be more effective at reducing the negative consequences of alcohol use (50). Focusing on responsible drinking later in life, and an inclusive environment for younger experimenting peers, may reduce heavy drinking episodes and limit the related problems (49). Furthermore, a harm reduction approach may especially benefit learners who have already tested alcohol and may lead to less stigma and marginalization of these children. Overall, the use of zero tolerance and danger rhetoric approaches do not reflect the realities the Ugandan children face daily and do not equip them with tools to prevent harm from alcohol consumption (53). The legal drinking age in Uganda is 18, but many children consume earlier(11, 13, 27, 62). The schools could prepare learners with more nuanced and age-appropriate information and contribute to reduced harm.
Strengths and limitations
By using different data sources, we were able to capture the alcohol education from both the learners’ and teachers’ perspectives. Through purposive sampling we included schools with different characteristics, thus the data was collected from a broad demographic spectrum of participants and captured a wider range of opinions. The two Ugandan research assistants moderated the FGDs in the preferred language by the children to improve cultural sensitivity. The same researchers also transcribed and translated the data. To minimize cultural bias of the first author, she worked closely with local data collectors and was advised by a Ugandan supervisor (JNB). Furthermore, the results were validated within the wider research group, Ugandan national stakeholders and with 6 teachers who participated in the interviews.
We stratified the focus groups by gender to increase homogeneity within the group to facilitate a favourable group dynamic. The groups were not divided by age nor grade which may have influenced the group dynamic possibly silencing the younger children. Since learners were selected from the same school for each FGD, the group dynamic and psychological safety of the participants may also have been influenced by existing peer and social structures. We note that not all learners aged 11–13 years had completed grade 6 and their experiences were therefore limited to the curriculum they had been taught. We accepted this because we preferred to obtain a more diverse group of participants. Collaborating with the teachers was deemed appropriate as they were familiar with the children, their parents, and the community, thus facilitating access to the study participants. We acknowledge that this approach is prone to selections bias because teachers may have selected favored and best achieving learners within the eligible population. Thus, this study may not have captured the most vulnerable population of primary school learners. However, this approach to sampling ensured access to the participants and selection of children who were comfortable with expressing themselves. Furthermore, some learners perceived the discussion as an evaluation of their knowledge rather than an inquiry into their experiences and opinions. Likewise, some teachers were reluctant to talk about alcohol issues within their school, opting instead to give examples from previous employment or other schools in the area. We suspect that conducting interviews and discussions on school premises during school hours may have caused participants to be more constrained. Lastly, we recognize that due to using translated FGD transcripts we compromised original expressions and concepts. To mitigate this, the same moderators transcribed and translated the data to maintain its integrity.
Implications
This study explored the teachers’ and learners’ perspectives on alcohol education. Factors such as improved student-teacher ratio, stronger collaboration between teachers and the health sector and improved teacher skills with counselling can all benefit the health of the children. Studies suggest that out of school youth in Uganda consume more alcohol, thus, better retention rates in school and interventions on alcohol are important for improving health in Uganda (63). Furthermore, effective alcohol policies need to be implemented to support alcohol education in schools, limiting the availability and promotion of alcohol, especially targeting children and youth (2, 9). Lastly, more research on child alcohol use and effective school-based alcohol interventions are needed in Africa and Uganda.