Regulating alcohol packaging and supply to protect health in Sub-Saharan Africa: evidence from policy systems in Malawi and Uganda

在全球范围内，饮酒会导致癌症和其他非传染性疾病，2016年有300多万人因有害使用酒精而死亡（每20例死亡中有1例）。它对经济生产力产生影响，并可能导致成瘾、暴力行为、伤害和道路交通碰撞。它还对卫生系统产生影响，特别是在低收入和中等收入国家，这些国家的卫生系统已经面临重大挑战。非洲饮酒者每天的饮酒量比全球平均水平高出21%。装有酒精或烈酒的一次性小塑料袋导致马拉维和乌干达最脆弱和最贫穷社区，特别是年轻人严重酗酒。因此，马拉维和乌干达在马拉维（2016年）和乌干达（2019年）对小袋酒精实施了全国禁令，但这些禁令可能没有产生预期的影响。2019年3月，我们与来自马拉维和乌干达等6个中低收入国家的研究人员组织了一次研讨会，讨论有关酒精消费的问题，以及可以开展哪些研究来支持控制酒精供应的有效政策。马拉维和乌干达的同事提出了酒精小袋和禁止它们的政策的问题，他们认为有必要研究禁令的执行情况，比较两国，看看可以吸取什么教训。我们这项研究的目的是了解禁令被采用的原因以及它们是如何被提出的，提出和实施的机制是什么，禁令是如何在实践中执行的，以及可能发生的意想不到的后果。我们将通过与政策制定者和主要利益攸关方的访谈，以及与执法和贸易方面的地区和地方利益攸关方的访谈来做到这一点。我们还将与男女、地方保健中心的保健工作人员以及传统/教会领袖和学校校长进行焦点小组讨论，探讨禁止有害形式的酒精消费的预期影响以及禁令的任何意想不到的后果（例如，增加家庭酿造的消费）。我们还将审查社区内和年轻人对有害饮酒变化的看法；以及当地卫生机构的工作人员是否因为禁令而在设施层面上看到了成瘾和伤害方面的变化。我们将在马拉维和乌干达的特别活动上与利益攸关方分享我们的成果。为了实现我们的目标，我们组建了一个由来自不同学科（社会科学、流行病学、心理学、人口和公共卫生）的七名经验丰富的研究人员组成的团队。其中4人在乌干达和马拉维，他们将在那里领导这项研究，另外2人在南非。我们将在乌干达和马拉维招募全职研究人员开展这项工作，并将培训他们有信心开展酒精研究，从而影响政策并帮助减少与酒精有关的危害。我们还组建了一个国际咨询小组，由来自高收入国家的2名专家和来自非洲低收入和中等收入国家酒精问题网络的7名专家组成。我们将从头到尾与每个国家以及其他非洲和全球网络的利益攸关方密切合作，使他们有机会在其背景下了解我们的研究结果，以便他们能够将这些发现用于政策制定、宣传和支持进一步的研究。

Consuming alcohol ('drinking') causes cancers and other NCDs globally and more than 3 million people died due to harmful use of alcohol in 2016 (1 in 20 deaths). It has impacts on economic productivity and can lead to addiction, violent behaviours, injuries, and road-traffic collisions. It also impacts on health systems, particularly in low and middle income countries (LMIC) where those system already face significant challenges. Drinkers in Africa consume 21% more alcohol per day than the global average. Small disposable plastic sachets which contain alcohol or spirits have led to significant alcohol abuse amongst the most vulnerable and poorest communities in Malawi and Uganda, particularly the young. As a result Malawi and Uganda placed national bans on sachets of alcohol in Malawi (2016) and Uganda (2019), but those may not have had the impact anticipated. In March 2019, we organised a workshop with researchers from 6 LMICs including Malawi and Uganda to discuss issues around alcohol consumption and what research could be done to supports effective policies to control the supply of alcohol. The issue of the alcohol sachets and the policies to ban them was raised by Malawi and Uganda colleagues, who felt it was needed to study the implementation of the bans, to compare both countries and to see what lessons could be learnt.Our aims with this study are to understand why the bans were adopted and how they were presented, what mechanisms for implementation were proposed and put in place, how the bans were enforced in practice, and what unintended consequences may have occurred. We will do this through interviews with policy makers and major stakeholders, and also, through interviews with district and local stakeholders in enforcement and trade. We will also conduct focus group discussions with men and women, health staff from local health centres and with traditional/ church leaders and school headteachers, to explore the perceived impact of the ban on harmful forms of alcohol consumption and any unintended consequences of the bans (e.g. increased consumption of home brews). We will also examine perceptions of changes in harmful drinking within the community and amongst young people; and whether local health facility staff have seen changes in terms of addiction and harm at facility level because of the bans. We will share our results with stakeholders at special events in Malawi and Uganda.To achieve our aims we have assembled a team of seven highly experienced researchers from different disciplines (social science, epidemiology, psychology, population, and public health). Four of them are based in Uganda and Malawi where they will lead the research and two in South Africa. We will recruit full-time researchers in Uganda and Malawi to carry out the work and will train them to have the confidence to carry out alcohol research which can influence policy and help reduce alcohol-related harms. We have also assembled an international advisory group with 2 experts from high income countries and 7 from African low and middle income countries networks on alcohol We will work closely with stakeholders in each country and other African and global networks from start to finish, to give them an opportunity to understand our findings in their context, so they can use those findings in policy development, for advocacy, and to support further research.