Globally, 5.9% (3.3 million) of all deaths and 5.1% of the global burden of disease are attributable to alcohol use [1]. As of 2010, the average per-capita alcohol consumption for South Africa was 11 litres and the percentage of alcohol use disorders was 5.6%, compared to 6 litres per capita consumption and 3.3% for alcohol use disorders on the African continent [1]. In South Africa, alcohol use contributes significantly to death and disability, causing 6.1% of all deaths, 7.4% of premature deaths and 6.2% of disabilities, altogether representing 7.0% of the burden of disease [2]. The age-standardised death rate from alcohol-related causes and the alcohol attributable fraction for cirrhosis in South Africa are 25.2 per 100 000 and 68.4% for males and 8.9 per 100 000 and 59.6% for females, respectively [1].

While alcohol use is a component cause of more than 200 chronic diseases and conditions, it is the necessary cause of all alcohol-use disorders such as alcohol dependence and harmful alcohol use, as defined in the tenth edition of the International Classification of Disease (ICD-10) [3, 4]. Alcohol use can lead to an increased risk of hypertension, cardiovascular and liver diseases, acute and chronic pancreatitis, risky sexual behaviour, non-adherence to antiretroviral treatment, spontaneous abortions and foetal development disabilities [3-6]. Harmful alcohol use has causal relationships with many chronic diseases and new evidence suggests similar relationships with pneumonia, tuberculosis and HIV/AIDS [1]. The drinking pattern score and years of life lost score for South Africa are both 4 out of a possible 5, representing risky drinking patterns and increased loss of life [1].

University students are a generally young and adventurous population whose alcohol-use habits are dangerous and irresponsible, characterised by higher binge-drinking frequencies than is found among older adults [7, 8].Their reasons for alcohol use include, among others, relative ease of access to alcohol, ignorance of associated harm, the stress of university life, peer pressure, relaxation and experimentation [9, 10]. Whatever the reason, bad decisions at this stage of life can negatively affect academic performance and the health and wellbeing of students in the short and/or long term [11, 12]. Some studies on undergraduate students found that the students consider alcohol use to be a socially desirable habit [7, 13]. Different studies have identified various sets of variables as predictors of alcohol use at universities, including, but not limited to, gender, religion, income, peer pressure and campus residence, parental alcohol use, socioeconomic status, age at first alcohol exposure, year of study and academic faculty [12, 14-16].

A study on alcohol use among secondary school learners in KwaZulu Natal found that 54% of learners had consumed alcohol at some point, and of these, 32% had participated in binge and/or episodic drinking [12]. Eze et al. [17] found that 55.2% of male learners and 44.8% of female learners at a secondary school in Nigeria had experimented with alcohol or were current alcohol users. The prevalence of hazardous and harmful alcohol use was found to be at least 50% at some university campuses in South Africa [15]. At one university in the Eastern Cape, about 52% of students were found to use alcohol harmfully [16]. A study on male students at a university in Southeast Nigeria estimated the prevalence of alcohol use to be 78.4%, of which 27% were risky alcohol users [18], and a similar study involving undergraduate students’ alcohol use in Nigeria reported a prevalence rate of 72% [19]. A cross-sectional study at Makerere University in Uganda found an alcohol use prevalence rate of 55.6% [20]. These studies show that at least half of the students at some universities use alcohol.

The literature reveals that university students have adequate knowledge of the consequences of risky alcohol use on physical and social health [21]. Peltzer et al. [22] found no association between alcohol use and knowledge of its links to cardiovascular disease and hypertension. A study at a South African university found that the students acknowledge the link between alcohol use and cirrhosis but lack the knowledge of the links with hypertension, cancer and diabetes [13]. Research on undergraduate students at Makerere University in Uganda found that students at that institution had adequate knowledge of both the short-term and long-term consequences of alcohol use [20].

There is very little information on alcohol use among university students in Eastern Cape Province, South Africa. The few studies that have been carried out did not examine the knowledge of the students regarding alcohol-attributable health conditions [16, 23]. The aim of this study was to examine the knowledge of university students concerning alcohol use patterns and long term alcohol-attributable health conditions; and to relate this knowledge to alcohol use patterns and biographical variables. The findings of the study might help in the development of risk reduction and/or health promotion interventions to reduce the incidence of alcohol use among university students, while increasing their alcohol-related health knowledge.

This cross-sectional study involved 213 undergraduate university students enrolled for first level statistics service courses at one university in South Africa. The university has three campuses. The A campus is located in a rural setting, while B and C campuses are in an urban settings. The target population was undergraduate students who take the first level statistics courses as part of the requirements for their degree programmes. This was a prevalence study of a finite population of undergraduate university students. As such, the required sample size was determined using the finite population correction sample size calculation formula [24] below:

where n is the sample size, N is population size, P is the hypothesised prevalence, d is the desired precision of the prevalence estimate and α is the significance level.

Based on a first level statistics enrolment of 468 undergraduate students in 2016, a significance level of 5%, a margin of error of 5% and hypothesised prevalence of 50%, the minimum required estimated sample size was 211 students. In order to compensate for possible withdrawals or non-response, 250 students were randomly selected from class lists at each campus. The simple random sampling feature of the MS EXCEL software was used for the participant selection process.

The gender, university campus, residence status, employment status and educational level of parents, degree programme and year of study were identified as biographical variables of interest for the study. The English version of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire was used to measure alcohol use [25]. The overall alcohol use score for a given individual was calculated as the sum of the scores on the 10 AUDIT items. The definition of a standard drink was as given in [25]. Most of the university students who use alcohol prefer beers/lagers, spirits and ciders [7]. Two binary variables were derived from the AUDIT instrument, namely, alcohol use status and alcohol use extent. From the whole sample, students with AUDIT sum scores greater than 0 were defined as alcohol users and alcohol users with AUDIT sum scores greater than 8 were defined as risky alcohol users. All others were either users or safe users [16, 25].

Besides questions on biographical characteristics and alcohol use, the questionnaire included 30 items on knowledge of alcohol-attributable health conditions. The health knowledge questions were formulated based on the health consequences for drinkers as indicated in the WHO Global Status Report on Alcohol and Health [4] and Shield et al. [26]. The questions were of a true/false nature and covered cardiovascular disease, cancer, gastrointestinal disorders, diabetes, mental health and reproductive health. One health knowledge variable was derived as a proportion of the total number of correct answers to the health knowledge questions, expressed as a percentage.

The University of Fort Hare’s Research Ethics Committee (UREC) gave approval for the study (Ref:GOO051SMAN01). The students were randomly identified, then invited for a study briefing. After the briefing, those who were interested were asked to sign an informed consent form prior to completing the questionnaire. The students completed the questionnaires in a designated quiet place secured for the purpose of data collection. Of the 250 sampled students, 221 gave their consent to participate in the study. Of the 221 completed questionnaires, 3.6% were incomplete and subsequently excluded from the analysis. This resulted in an effective sample size of 213 students.

Means and standard deviations were used to describe age and health knowledge while frequencies and percentages were used to summarise the categorical biographical variables and alcohol use variables. The significance of bivariate associations between alcohol use variables and biographical variables was tested using the chi-squared test for independence. This was followed up with odds ratios as measures of strength and direction of associations. The Mann-Whitney two samples test was used to compare age and health knowledge across the categories of alcohol-use status and extent. A multiple logistic regression of alcohol use and alcohol use extent on and health knowledge and student-specific biographical variables was carried out to determine the pattern of associations. All tests for statistical significance were carried out at a 5% level of significance and were performed using the SAS (Statistical Analysis Systems) software version 9.4.

The study sought to determine alcohol use patterns and knowledge of alcohol-attributable health conditions among university students in the Eastern Cape, South Africa, on which information is currently lacking. The prevalence of alcohol use was moderately high (58.2%), and comparable to the findings obtained in other universities in South Africa [15, 29-31]. Young and De Klerk [16] found a prevalence of 52.7% at Rhodes University, which lies 106 km to the south-east of the University of Fort Hare’s Alice campus, and 160 km west of Fort Hare’s East London campus. Compared with other studies in South Africa and elsewhere, alcohol use prevalence among university students in this study was moderately high. Olukemi et al. [21] found an alcohol use prevalence of 62.0% at a Nigerian university. Kyei et al. [15] found an alcohol use prevalence of 65.0% and a risky alcohol use prevalence of 49.0% among alcohol users at the University of Venda. Davoren et al. [32] estimated an alcohol use prevalence of 66.4% at an Irish university. Chauke et al. [33] found a high-school alcohol use prevalence of 35.5% at a school in KwaZulu Natal Province in South Africa. Given such a high prevalence rate at high school, the 50.0% prevalence rate at some universities is not surprising. Bearing in mind the contribution of alcohol-attributable health conditions on the burden of disease, these results suggest that alcohol use among university students is a potential public health problem.

In this study, there was generally little knowledge of the long-term effects of alcohol use among the students. This is consistent with the findings from other studies that looked at knowledge of the long-term effects of alcohol on the health of users [13, 22]. Alcohol users in this study were more knowledgeable of the long-term health effects of alcohol use than those in some studies. The dissemination of alcohol-related health information is usually targeted at the general population, while some safe alcohol use campaigns specifically target alcohol users through events in social spaces where alcohol consumption is not restricted. Alcohol users are likely to pay attention to the health promotion materials because they are stakeholders. Conversely, non-users may find the information irrelevant to them because they do not practise the behaviour.

This study showed that socioeconomic status, measured through educational level and employment status of the father, is a significant predictor of health knowledge. This is a plausible outcome, especially regarding educational level, based on the assumption that higher educational level is associated with higher ability to understand and value information. However, students with employed fathers are likely to have access to more financial resources and therefore more money to sponsor alcohol use habits. Results from other studies show that high socioeconomic status is associated with a higher risk of alcohol use [7, 15, 29-31]. However, there is no consensus on the influence of socioeconomic status on the decision to experiment with alcohol and other substances [32]. This study identified father’s employment status as the only socioeconomic variable associated with alcohol use. The Eastern Cape is a poor and rural province in South Africa. The province is characterised by high unemployment. The few that are employed are predominantly male, and as such, father’s employment status would be a good proxy for socioeconomic status.

Both alcohol use and risky alcohol use were lower among the female students than among the males. This is consistent with the findings of other studies on alcohol use among university students and adolescents [9, 12, 14, 15, 29, 33-35]. However, one study found no significant gender difference in alcohol use among university students [36]. Males tend to consume alcohol more than females, in terms of the quantity of alcohol and frequency of use [7, 13].

Similar studies carried out with university students elsewhere also found that returning students have a higher likelihood of alcohol use than first-year students [9, 16, 34]. This is probably due to the fact that first-year students would still be familiarising themselves with the university environment. However, in contrast to the above findings, Govender et al. [37] found that alcohol use was higher among first-year students than among returning students. It is worth noting that alcohol experimentation is already high at the school level in South Africa [38]. Given the freedoms associated with university life, it may be reasonable to expect that alcohol and substance experimentation would be higher among first-year university students. This difference in results suggests that alcohol use habits are not necessarily homogeneous across different universities.

Rural campus students were at a higher risk of unsafe alcohol use than urban campus students. The lack of recreational opportunities at the rural campus might cause students to resort to excessive alcohol consumption. In addition, the cost of living in the urban setting is generally high and financially more demanding than rural life, and it is possible that students in an urban setting have less disposable money for alcohol. Notably, students residing on a rural campus enjoy favourable alcohol prices compared to urban students, who would have to drink in hotels at higher costs, or

could drink in cheaper but overcrowded and criminally risky drinking places in close proximity to the campus residences.

The findings of the study show that slightly more than half the students use alcohol, and of these, the majority are safe alcohol users. The chances of alcohol use are higher among males, seniors and those with employed fathers than among females, first years and those with unemployed fathers, respectively. With respect to health knowledge, alcohol users and those whose fathers have post-primary education were significantly more knowledgeable than non-users and those whose fathers have primary education, respectively. Among those that use alcohol, the chances of risky alcohol use are higher among males and students with employed fathers than among females and those with unemployed fathers, respectively. While gender and father’s employment status are significant predictors of alcohol use, gender, father’s employment status and campus are significant predictors of risky alcohol use. Health knowledge is low, regardless of individual biographical variables and extent of alcohol use. The prevalence of alcohol use is moderately high and health knowledge is low regardless of risky alcohol use. The likelihood of alcohol use, risky and non-risky, is higher among males, those in rural environments and those with high socioeconomic status. While knowledge of alcohol-attributable health conditions is generally low, alcohol users and those with educated parents are more knowledgeable.

The combination of lack of knowledge and the high prevalence of alcohol use provides fertile ground for possible future experimentation with alcohol among current non-users and increased consumption among current users. Health promotion and risk reduction interventions should be targeted at educating both users and non-users of alcohol about the value of a healthy lifestyle.