The lifetime prevalence of substance use in this study was 66.1%, a rate that is comparable to the 65% reported in the study among prisoners in Uganda [15
]. In a setting such as this where prison mental health services are grossly inadequate, the high prevalence of substance use is worrying given the well-established relationship between substance use, mental disorders and even personality disorders [6
]. This gap is however not unique to Kenya or other low income countries, as studies from higher income countries have also demonstrated the need for an increase in the provision of mental health services to cope with the high number of mentally ill inmates [4
Most substance users in this population were introduced to the habit by friends and family members. Other studies in the region have reported similar findings [22
]. The implication of this finding is that the approach to drug awareness campaigns should incorporate not only the youth but their parents and even older relatives in the same forum.
Those with a higher level of education, had lived in urban settings and were of the male gender had significantly higher rates of lifetime substance use, suggesting that schools and urban environments provide more opportunities for initiation into substance use for many young men. Oteyo and Kariuki in a 2009 study carried out in nine secondary schools in this same region found that among other factors peer group and family influence had the greatest contribution to high alcohol and cigarette use [27
]. However, the association between marital status and lifetime substance use in the current study was confounded by the other variables.
The lifetime prevalence of alcohol use in this study was 65.1%. This is much higher than that reported in the earlier Ugandan Prisons study [15
]. The possibility of some access to alcoholic beverages in the Kenyan prison setting cannot be completely discounted in an environment where ‘special operations’ by prison authorities regularly find many illicit belongings in the prison cells, including mobile phones, coins, cannabis and other drugs [28
]. It is however comparable to the prevalence of 62% reported by Othieno et al. in a study of outpatients attending several Nairobi primary health care facilities [18
Surprisingly, a current alcohol use was reported by some of the participants in this study. Due to the restriction of access to alcohol in a prison environment, this finding probably reflects the fact that some inmates had stayed in the prison for short enough durations of time to have had a drink before incarceration. However, the suggestion of illicit acquisition of alcohol cannot be discounted [28
Notable though was the earliest reported age at first drink of 7 years. This is even younger than what has been reported in earlier studies in this region [19
]. The fact that most alcohol consumed in Kenya comes from small-scale illicit brews that are produced and sold in homes may explain the early availability of alcohol to children in such homes [29
Some of the negative effects attributed to alcohol use in this study included engaging in quarrels and arguments, scuffles and fights, unprotected sex, property damage, trouble with the police, suffering blackouts, medical problems and discord relationships. Reported outcomes of early onset alcohol use include the possibility of dependence, other mental illnesses and difficulties adjusting in later life [24
]. In the present study, alcohol use was also associated with higher levels of education, being unmarried and living in an urban environment, further reflecting the role of peer influences and easy availability of alcoholic beverages to young people.
The habit of chewing tobacco and cigarette smoking was also reported by some of the participants in this study. The type of tobacco commonly chewed was ‘kuber’, a brand name for various preparations that may contain tobacco, slaked lime, areca nuts and betel quid leaf [32
]. Some participants also reported current tobacco chewing and smoking, suggesting that the illicit acquisition of these products cannot be discounted [28
], although the finding may be as a result of shorter durations of incarceration.
Cigarette use was significantly associated with male gender, younger age, urban residence and being unmarried. Student and income status association with cigarette use were shown to be confounded by other variables. Being married is a modifiable variable and seems to be a protective factor in relation to the habit. Chewing tobacco might also be a cheaper option for those younger unmarried males in an urban residence with the need to experiment. As it may not be fashionable to be seen chewing tobacco among those with a source of income, smoking cigarettes was more acceptable in this population. Studies have suggested that cigarette use appears fashionable, and is often the first drug many young people are exposed to, before diversifying to other substances [16
The lifetime prevalence of cannabis use was 21%, a finding similar to the rate of 26.7% found in a 2003 study in France [33
], but much lower than that (49%) in the Ugandan study [15
]. Similarly, Odek Ogunde et al. [34
] reported a rate of 19.7% in a study among students at a Kenyan university. Factors associated with lifetime cannabis use included being a student, unmarried, living in an urban residence and of the male gender. The implication is that peer influence and availability and accessibility of cannabis play a role in cannabis initiation and use. Further research is necessary to examine the exact relationship between these variables and cannabis use.
Some participants in the current study reported cannabis initiation as early as at the age of 9 years. Considering the evidence of psychological dependence and high risk of mental illness associated with cannabis use [25
], this finding needs to be taken into consideration in the formulation of mental health promotion campaigns.
Despite the relatively low lifetime prevalence for the use of other substances reported in this study, the findings are much higher than those determined among high school, college and university students in the same region [22
]. However, this is in keeping with findings in correctional facilities elsewhere, further supporting the association between substance use and criminality [1
]. Additionally, cocaine and heroin use was also reported in the current study unlike in the earlier Ugandan study [15
]. This is a worrying trend that requires further assessment which should specifically include examining for the documented complications of injecting drug use [20
Reasons given for using substances include to relax, to relieve stress, to experiment, to feel normal, to be accepted by peers, easy availability of the substances and the confidence to commit a crime. These reasons are similar to those given by substance users in other studies, except for the additional ‘confidence to commit a crime’ [22
The results from the present study suggest a need for the enforcement of measures aimed at reducing availability and accessibility of substances, given that it has been suggested before that the substance use problem in many countries is largely due to a failure of the enforcement of existing regulations [29
Among the limitations in this study was the fact that the period of incarceration for the prisoners was not determined. This may have resulted in the reports of current substance use, especially among the new arrivals in the prison. It also makes it difficult to arrive at any conclusions concerning the availability of alcohol and other substances in the prison environment.
Due to the cross-sectional nature of this study, it is not possible to make any conclusions as to the causal relationships between the various variables and substance use. A longitudinal study would be better suited for this sort of analysis.
There are two categories of prisons in Kenya; the first is a general prison, such as the one at which this study was carried out, while the second is the maximum security category. The crime profiles are different at these two prison types, and it therefore follows that our findings cannot be generalised to the entire prison population in the country. However, this study provides valuable insights that may serve as the basis for the conduct of a nationwide study of substance use among inmates in Kenyan prisons.
Information concerning the type of crimes that had been committed by the clients prior to incarceration was also not collected in this study. This would have been invaluable evidence- based data in determining any association between drug crimes or related drug use and incarceration. Further, it would have enabled comparison with findings from other settings.
Finally, in this study, there was no attempt to screen for or diagnose mental disorders. The complex relationship between mental illness and substance use suggests that any future study of this nature must take into consideration the need to screen for mental disorders as well. This would provide useful planning information as regards financial and human resource allocation for mental health services in Kenyan prisons.