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Alcohol-related harm has gained increased attention in high-income countries (HICs) in recent years which, alongside government regulation, has effected a reduction in alcohol consumption. The alcohol industry has turned its attention to low-income and middle-income country (LMIC) markets as a new source of growth and profit, prompting increased consumption in LMICS. Alcohol use in LMICs is also increasing. There is a need to understand particularly in LMICs the impact of industry strategy in shaping local contexts of alcohol use. We draw on conceptualisations from food systems research, and research on the commercial determinants of health, to develop a new approach for framing alcohol research and discuss implications for alcohol research, particularly in LMICs, focusing on South Africa as an illustrative example. We propose a conceptualisation of the ‘alcohol environment’ as the system of alcohol provision, acquisition and consumption—including, critically, industry advertising and marketing—along with the political, economic and regulatory context of the alcohol industry that mediates people’s alcohol drinking patterns and behaviours. While each country and region is different in terms of its context of alcohol use, we contrast several broadly distinct features of alcohol environments in LMICs and HICs. Improving understanding of the full spectrum of influences on drinking behaviour, particularly in LMICs, is vital to inform the design of interventions and policies to facilitate healthier environments and reduce the harms associated with alcohol consumption. Our framework for undertaking alcohol research may be used to structure mixed methods empirical research examining the role of the alcohol environment particularly in LMICs.

In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems.

Objective. We assessed the effectiveness of South Africa’s Firearm Control Act (FCA), passed in 2000, on firearm homicide rates compared with rates of nonfirearm homicide across 5 South African cities from 2001 to 2005. Methods. We conducted a retrospective population-based study of 37 067 firearm and nonfirearm homicide cases. Generalized linear models helped estimate and compare time trends of firearm and nonfirearm homicides, adjusting for age, sex, race, day of week, city, year of death, and population size. Results. There was a statistically significant decreasing trend regarding firearm homicides from 2001, with an adjusted year-on-year homicide rate ratio of 0.864 (95% confidence interval [CI] = 0.848, 0.880), representing a decrease of 13.6% per annum. The year-on-year decrease in nonfirearm homicide rates was also significant, but considerably lower at 0.976 (95% CI = 0.954, 0.997). Results suggest that 4585 (95% CI = 4427, 4723) lives were saved across 5 cities from 2001 to 2005 because of the FCA. Conclusions. Strength, timing and consistent decline suggest stricter gun control mediated by the FCA accounted for a significant decrease in homicide overall, and firearm homicide in particular, during the study period.

To estimate the magnitude and characteristics of the injury burden in South Africa within a global context. The Actuarial Society of South Africa demographic and AIDS model (ASSA 2002) - calibrated to survey, census and adjusted vital registration data - was used to calculate the total number of deaths in 2000. Causes of death were determined from the National Injury Mortality Surveillance System profile. Injury death rates and years of life lost (YLL) were estimated using the Global Burden of Disease methodology. National years lived with disability (YLDs) were calculated by applying a ratio between YLLs and YLDs found in a local injury data source, the Cape Metropole Study. Mortality and disability-adjusted life years' (DALYs) rates were compared with African and global estimates. Interpersonal violence dominated the South African injury profile with age-standardized mortality rates at seven times the global rate. Injuries were the second-leading cause of loss of healthy life, accounting for 14.3% of all DALYs in South Africa in 2000. Road traffic injuries (RTIs) are the leading cause of injury in most regions of the world but South Africa has exceedingly high numbers - double the global rate. Injuries are an important public health issue in South Africa. Social and economic determinants of violence, many a legacy of apartheid policies, must be addressed to reduce inequalities in society and build community cohesion. Multisectoral interventions to reduce traffic injuries are also needed. We highlight this heavy burden to stress the need for effective prevention programmes.

To investigate injury-related mortality in South Africa using a nationally representative sample and compare the results with previous estimates. We conducted a retrospective descriptive study of medico-legal postmortem investigation data from mortuaries using a multistage random sample, stratified by urban and non-urban areas and mortuary size. We calculated age-specific and age-standardized mortality rates for external causes of death. Postmortem reports revealed 52,493 injury-related deaths in 2009 (95% confidence interval, CI: 46,930-58,057). Almost half (25,499) were intentionally inflicted. Age-standardized mortality rates per 100,000 population were as follows: all injuries: 109.0 (95% CI: 97.1-121.0); homicide 38.4 (95% CI: 33.8-43.0; suicide 13.4 (95% CI: 11.6-15.2) and road-traffic injury 36.1 (95% CI: 30.9-41.3). Using postmortem reports, we found more than three times as many deaths from homicide and road-traffic injury than had been recorded by vital registration for this period. The homicide rate was similar to the estimate for South Africa from a global analysis, but road-traffic and suicide rates were almost fourfold higher. This is the first nationally representative sample of injury-related mortality in South Africa. It provides more accurate estimates and cause-specific profiles that are not available from other sources.

Alcohol use has widespread effects on health and contributes to over 200 detrimental conditions. Although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions. Population surveys, which are the main source of data on alcohol exposure, suffer from bias and uncertainty. This article proposes a novel triangulation method to reduce bias by rescaling consumption estimates by sex and age to match country-level consumption from administrative data. We used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. Independently for each survey, we calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories. We used these aggregated results, together with data on alcohol production, sales and import/export, as inputs of a Bayesian model and generated yearly estimates of the prevalence of drinkers in the population and the parameters that characterise the distribution of the average consumption among drinkers. Among males, the prevalence of drinkers decreased between 1998 and 2009, from 56.2% (95% CI 53.7%; 58.7%) to 50.6% (49.3%; 52.0%), and increased afterwards to 53.9% (51.5%; 56.2%) in 2016. The average consumption from 52.1 g/day (49.1; 55.6) in 1998 to 42.8 g/day (40.0; 45.7) in 2016. Among females the prevalence of current drinkers rose from 19.0% (17.2%; 20.8%) in 1998 to 20.0% (18.3%; 21.7%) in 2016 while average consumption decreased from 32.7 g/day (30.2; 35.0) to 26.4 g/day (23.8; 28.9). The methodology provides a viable alternative to current approaches to reconcile survey estimates of individual alcohol consumption patterns with aggregate administrative data. It provides sex- and age-specific estimates of prevalence of drinkers and distribution of average daily consumption among drinkers in populations. Reliance on locally sourced data instead of global and regional trend estimates better reflects local nuances and is adaptable to the inclusion of additional data. This provides a powerful tool to monitor consumption, develop burden of disease estimates and inform and evaluate public health interventions.

BackgroundAlcohol use is a well-established potentially modifiable risk factor for suicide, yet few studies have investigated the impact of alcohol restrictions on suicide rates, particularly in low- and middle-income countries.MethodsWe used data from nationally representative annual surveys of postmortem investigations in 2017 (n=6117) and 2020/21 (n=6586) to estimate changes in suicide rates associated with the COVID-19 pandemic and related alcohol restrictions.FindingsAge standardised suicide mortality rates per 100 000 were 10.91 (10.64, 11.18) in 2017 and 10.82 (10.56, 11.08) in 2020/2021, with approximately 4.4 times more deaths among males than females in both periods. No significant differences were observed between overall suicide rates during the 2020/2021 pandemic period compared with 2017 (risk ratio=1.04 (1.00, 1.07)), but in the 15–24-year age group, suicide rates were 11% higher among males and 31% higher among females than in 2017. Partial alcohol restrictions during the pandemic were not associated with lower suicide risk. However, the shift from partial to full restriction on the sale of alcohol was associated with an 18% (95% CI 10% to 25%) reduction in suicides for both sexes combined and a 22% (95% CI 13% to 30%) reduction in suicides among men, but no significant reduction among women.InterpretationOur findings offer some support for the hypothesis that restricting access to alcohol at a population level is associated with a reduction in suicide rates and suggests that restricted access to alcohol may have been one of the reasons global suicide rates did not increase during the pandemic in some countries.

Injuries, often preventable, prompted urgent action within the United Nations' 2030 Agenda for Sustainable Development Goals (SDGs) to improve global health. South Africa (SA) has high rates of injury mortality, but accurate reporting of official national data is hindered by death misclassification. Two nationally representative surveys for 2009 and 2017 are utilised to assess SA's progress towards SDG targets for violence and road traffic injuries, alongside changes in suicide and under-5 mortality rates for childhood injuries, and compare these estimates with those of the Global Burden of Disease for SA. The surveys utilised multi-stage, stratified cluster sampling from eight provinces, with mortuaries as primary sampling units. Post-mortem files for non-natural deaths were reviewed, with additional data from the Western Cape. Age-standardised rates, 95% confidence intervals (CIs), and incidence rate ratios (IRRs) were calculated for manner of death rate comparisons and for age groups. The all-injury age-standardised mortality rate decreased significantly between 2009 and 2017. Homicide and transport remained the leading causes of injury deaths, with a significant 31% decrease in road traffic mortality (IRR = 0.69), from 36.1 to 25.0 per 100 000 population. Despite a reduction in SA's road traffic mortality rate, challenges to achieve targets related to young and novice drivers and male homicide persist. Achieving SA's injury mortality SDG targets requires comprehensive evaluations of programmes addressing road safety, violence reduction, and mental well-being. In the absence of reliable routine data, survey data allow to accurately assess the country's SDG progress through commitment to evidence-based policymaking.