In Uganda, children arrive at health facilities every day with fever, cough, injuries or routine illnesses. What health workers rarely recognise is that some of these children are already living with alcohol or other substance use disorders, conditions that complicate diagnosis, delay treatment, and quietly undermine children’s health, development, and long-term wellbeing.

This hidden reality was uncovered by Dr. Harriet Aber Odonga during her doctoral research at Makerere University School of Public Health (MakSPH). Her PhD study, titled “Substance Use among Children in Mbale, Uganda: Health System Landscape and Support Structures,” examined how Uganda’s health system detects and responds to substance use among children aged six to 17 years.

The findings revealed a problem far more widespread than many health workers and caregivers assumed. Nearly one in four children attending health facilities showed signs of alcohol or other substance use problems, with alcohol the most common substance. In the study, a child was classified as having a “probable” substance use disorder when responses to a standard screening questionnaire indicated harmful or dependent patterns of use requiring further clinical assessment.

The discovery adds urgency to an already serious public health challenge. Globally, alcohol and other substance use is responsible for one in five deaths and contributes to more than 200 disease and injury conditions, according to WHO. Across Africa, alcohol alone accounts for 6.4 per cent of all deaths and 4.7 per cent of disability-adjusted life years. In Uganda, alcohol use disorder affects roughly 7.1 per cent of the population and contributes to about 7% of all deaths, while research among young people shows that alcohol exposure often begins early in life.

Despite these risks, most policy and research attention has historically focused on adults and older adolescents. Much less is known about children who begin experimenting with alcohol and other substances earlier in their childhood, a gap Aber set out to examine by studying how Uganda’s health system identifies and responds to substance use among children.

A research question begins

Aber’s interest in the subject began unexpectedly. “I remember seeing a notice calling for PhD students to research child alcohol use,” Dr. Aber recounted. “The phrase struck me immediately. I could not believe that children were drinking alcohol. That moment sparked my curiosity, so I began reviewing the literature on the subject in Uganda. During that search, I came across a study documenting alcohol use among children as young as five years old. That finding was deeply unsettling and raised many questions for me.”

With a longstanding interest in child health, Aber saw the research as an opportunity to investigate a problem that had received little systematic attention. What began as disbelief developed into a doctoral investigation examining how Uganda’s health system identifies and responds to substance use among children. She began her doctoral studies in 2021 at MakSPH under the supervision of Dr. Juliet N. Babirye, Prof. Fred Nuwaha, and Prof. Ingunn Marie S. Engebretsen from the University of Bergen, Norway. She defended her thesis on October 25, 2025, before graduating during Makerere University’s 76th graduation ceremony on February 25, 2026.

Investigating the health system response

Aber’s study examined four key questions. It measured how common substance use disorders are among children visiting health facilities. It assessed whether health facilities are equipped to screen and manage these cases. It evaluated whether screening tools are acceptable to children, caregivers, and health workers. It also examined how families seek help when children begin using substances.

To answer these questions, the research used a mixed-methods design combining quantitative surveys and qualitative interviews. Aber collected data from 834 children attending health facilities in Mbale District, assessed 54 health facilities in the district to determine their readiness to screen and manage substance use disorders, and interviewed health workers, caregivers, and children to understand experiences of care and barriers to seeking help. Additional surveys involving 602 children and 355 caregivers examined help-seeking patterns and support structures.

Quantitative data were analysed to estimate prevalence and identify associated risk factors, while qualitative interviews provided insight into how families, communities and health workers respond when children begin using substances.

What the research found

Data collected between 2023 and 2024 across health facilities in Mbale District in Eastern Uganda showed that substance use among children was far more common than many health workers and caregivers assumed. Alcohol use disorder emerged as the most prevalent form of substance use disorder among children in the study. The analysis also showed that children were significantly more likely to use substances if they were exposed to peer or sibling use, lived in lower-income households, or experienced strained relationships with caregivers.

The research also revealed major health system gaps. Only 19 of the 54 health facilities assessed, representing 35 per cent, met the minimum readiness criteria required to screen, diagnose or manage substance use disorders. Many facilities lacked trained staff, standardised screening guidelines, and clear referral pathways for specialised care.

Aber explained that substance use often goes undetected because it is rarely the primary reason children visit health facilities. “Substance use is hidden,” she asserted, reflecting on evidence from her doctoral study. “While health workers are treating other illnesses, some children coming to these facilities are already struggling with alcohol or other substances.”

She added that early substance use can have lasting consequences for children’s development. “Risk was higher among children exposed to peer or sibling substance use, lower household income, lower caregiver education, and strained child-caregiver relationships. The public should be concerned because early substance use affects brain development, mental health, education completion, and long-term well-being.”

Families often navigate the problem alone

Her research also examined how families and communities respond when children begin using substances. She found formal help-seeking to be rare. Many caregivers relied on informal networks, including relatives, teachers, religious leaders, and local authorities. Health services were seldom the first point of support.

Meanwhile, punitive responses such as discipline or punishment were sometimes used by caregivers attempting to stop the behaviour of substance use among children, but these responses rarely addressed the broader social and family pressures influencing the vice.

One encouraging finding emerged from her study’s assessment of early detection tools. Aber evaluated the use of the CRAFFT screening tool, a short set of structured questions used by health workers to identify whether a child may be using alcohol or other substances. Children, caregivers, and health workers generally found the questions from the tool easy to understand and acceptable to use. In the study, over 85 per cent of children reported the questions were easy to answer, and nearly nine in ten caregivers were comfortable with the screening process.

These findings, however, suggest that routine early detection could be integrated into primary healthcare within the communities. “If policymakers were to act on one finding from my research, I would prioritise integrating routine, age-appropriate substance use screening into primary healthcare,” Aber argued. “With proper training and referral systems, health workers can identify early risk and support children before the problem escalates.”

Training across nutrition, public health and health systems

Aber’s approach to the problem reflects a research journey shaped by training across multiple areas of child and public health. She first studied Food Science and Technology at Kyambogo University, graduating in 2011, before specialising in Nutrition during her Master of Public Health at Makerere University, graduating in 2015, before embarking on her doctoral training in Public Health at the School, completing in 2025 to graduate at Makerere University 76^th Congregation.

Before beginning her PhD, she worked on nutrition research and later coordinated studies examining climate risks, anticipatory humanitarian action and community health systems. This background shaped how she approached substance use among children, not as an isolated behavioural problem but as an issue influenced by broader health and social conditions.

“I do not see child substance use as a problem with a single cause,” she noted. “It is influenced by biological, psychological, social, and system-level factors. My nutrition training helped me appreciate how substance use intersects with broader child health concerns such as mental health, family stress, and even food insecurity.” These pressures are visible in her research site in Mbale, where environmental shocks, economic hardship, and family instability persistently shape daily life. Recurrent landslides and livelihood disruptions place strain on households, and adolescents facing stress or instability may turn to substances as a coping mechanism, she holds.

From evidence to solutions

Completing her PhD has now shifted Aber’s perspective from documenting problems to identifying solutions for social impact. “Completing my PhD shifted my perspective from simply generating evidence to actively providing solutions,” she observed. “Child health challenges such as substance use, nutrition, and climate-related risks are interconnected. As a researcher, I have become more systems-focused, and as an advocate, I feel a stronger responsibility to ensure evidence informs policies that improve children’s wellbeing.”

For Aber, that responsibility extends to the families whose experiences informed the research. Parents, teachers, and health workers often notice behavioural changes first, even when they feel unprepared to respond. Listening without judgment, recognising warning signs, and linking children to appropriate support can make a significant difference, she noted, especially in a context where formal services remain limited.

Her research ultimately sends a clear message for Uganda’s health system. Children affected by substance use are already present in communities and health facilities. Detecting the problem earlier, strengthening screening systems, and equipping frontline health workers with appropriate tools could significantly improve outcomes for vulnerable children.

Behind the research journey stood a wide network of support, including MakSPH supervisors and doctoral committee, the TREAT consortium, the MakSPH PhD forum, the Health Development Centre secretariat, study participants, research assistants, family and friends, and funding support from the Government of Uganda through the Makerere University Research and Innovations Fund (MAKRIF) and the Norwegian Research Council, all of whom she remains grateful.

Aber’s research ultimately points to a critical gap in Uganda’s health system. Children affected by substance use are already present but remain largely invisible. Without routine screening, trained health workers, and clear referral systems, opportunities for early intervention are often missed. Addressing this gap, as indicated by her study, goes beyond clinical care. It requires strengthening how the health system recognises and responds to emerging risks that affect children’s long-term health and development.