Prevalence, associated factors and consequences of substance use among health and medical science students of Haramaya University, eastern Ethiopia, 2018: a cross-sectional study

Background Substance use has a terrible impact on health, behavior and country’s economy because the number of people particularly the youngsters being involved in this practice is increasing rapidly. However, the prevalence, determinants and consequence of substance use in the study area has been overlooked. Methods A descriptive quantitative cross-sectional study was conducted among 254 health science students of Haramaya University. The respondents were selected randomly after double stratification based on their department and batch respectively. A pre-tested self–administrable anonymous questionnaire was used. The collected data were entered into epidata version 3.1 and exported to SPSS version 23. Descriptive statistical analysis was done to examine findings. Besides, chi-square (X2) test was considered to examine the nonparametric association of factors with ever substance use. Results Prevalence of ever substance use for at least one substance was found to be 114(45.4%). Ever khat chewers take the highest percentage [107(93.9%)] followed by ever smokers 45(39.5%) and ever drinkers 44(38.6%). Among these ever substance users, 80(70.2%) were found to be current substance users. Being a preparatory student (26.3%) and freshman at university (57.9%) were critical times to initiate substance use. Sex, monthly income, sexual risk behavior and family history of substance use were found to be significantly associated with being ever substance user as witnessed by their respective X2 values of 19.67, 72.28, 28.99 and 139.72 at P-value = 0.05 and degree of freedom (df = 1). From the overall ever substance users, 31.6% had undesirable health consequences. Among these consequences, anorexia [40 (35.1%)] accounted for the highest percentage followed by insomnia [29 (25.4%)], depression [25 (22%)], gastritis [25 (22%)], dental caries [23 (20.2%)] and increased sexual activity [12 (10.5%)]. Conclusion Prevalence of ever substance use in the study area was relatively high. Therefore attention should be given to the major reasons for substance use mainly orientation of freshman students about better stress coping mechanisms and expansion of adequate recreational activities.


Background
Substance use has become one of the rising major public health and socio-economic problems worldwide. Hard drugs like cocaine are rarely available in Ethiopia where as Khat, alcohol and cigarette are commonly available and used substances [1]. Khat is originated from Ethiopia, especially in Hararghe region with the gradual expansion to the different parts of the country and other nations in Africa and Arabia [1][2][3][4][5][6]. According to the world health organization (WHO) estimation, approximately 47% of men and 12% of women smoke cigarette worldwide in 2010.The WHO regards smoking as pandemic while attributing more than 4 million deaths in a year to tobacco and it is expected that this figure will rise to 10 million deaths by the year 2020. More people smoke today than any other time in human history. One person dies every 10 seconds due to smoking-related diseases [7]. Smoking is practiced together with khat chewing and drinking alcoholic beverages that have many consequences [8]. Annually, in the United States, about half million people die of different diseases attributable to cigarette smoking. Thus, nearly 6 million years of potential life loss, $82 billion economic mess and $ 75 billion direct medical expenses were reported from the country. Furthermore, cigarette smoking has been considered as "an entry point" towards forbidden drug use among adolescents [9].Globally, 9% of the major noncommunicable diseases and 71% of lung cancer deaths are attributed to tobacco alone. These major noncommunicable diseases include atherosclerotic heart disease, myocardial infarction, heart failure, malignancy and diabetic mellitus that have paramount association and causal linkage with oral consumption of tobacco. Besides, socio-economic factors like education and occupational status were considered to be possible risk factors of these chronic non-communicable diseases. Therefore, practical consideration of efforts to modify these factors can bring a multitude of positive outcomes [10][11][12][13]. Alcohol drinking is spreading in universities and other tertiary academic institutions. In terms of gender, though men appear to drink more, women are also increasingly taking on this habit. Households are spending quality time in drinking and less on agricultural production [2]. Existing literature on alcohol consumption among adolescents in sub-Saharan Africa suggests that a substantial proportion of adolescents have consumed or currently consume alcohol [3,14] and alcohol use is generally believed to be the most important for sexual risk behavior in HIV/AIDS transmission because those addicted substances cause behavioral addictions like sex addictions resulting in important social and medical consequences [3]. High risk sexual behavior under the influence of alcohol is common in teenagers because alcohol is thought to fuel HIV transmission by blunting one's behavioral self-monitoring and increasing the likelihood of multiple sexual partners, unprotected sex, intergenerational sex and commercial sex [15][16][17][18][19][20][21][22][23]. Some studies have indicated that substance use resulted in psychological stress, suicidal attempts, functional impairment, physical ill health, and risk-taking behavior [8][9][10][24][25][26][27].-Substance use is influenced by different factors, for example, a cross-sectional study held at Harar town, Eastern Ethiopia, revealed that the use of khat was significantly associated with age, gender, Muslim religion, peer influence, and habit of family and other relatives among students [4,5]. One of the targets in the health goal of the sustainable development goals (SDGs) is to strengthen the prevention and treatment of substance use, including narcotic drug use and harmful use of alcohol. However, in the study area, there has been no prior study about the significance and associated factors of the problem since the launch of SDGs by 2015. Therefore, this study will help to show public health importance of the problem in response to the different preventive and therapeutic measures that have been taken into action since 2015.

Study area and period
This study has been conducted from January 16-30, 2018 at Haramaya University. Haramaya University was established in 1954 next to Addis Ababa University in Ethiopia. It is located about 510 km away from Addis Ababa in Oromia national regional state, East Hararghe administrative zone. The study programs of the university range from undergraduate (Diploma and first degree) to post graduate levels (MSc, Ph.D.) in its 3 campuses and 13 colleges. Among these colleges, College of Health and Medical Science is one of the colleges which was established in September 1996 with the objective of training health professionals who contribute to filling the gap of health need of the country, especially the rural population. It had 8 training programs: Medicine, Pharmacy, Comprehensive Nursing, Public Health, psychiatric Nursing, Midwifery, Medical laboratory technician and Environmental health science.

Study design and participants characteristics
A descriptive institution based quantitative crosssectional study design was conducted to determine the prevalence, associated factors and consequences of substance use among students of the college of health and medical science at Haramaya University. All regular health and medical science students of the college were included for the study. Students who were critically ill (unable to read and write) and physically impaired (had a hearing and speaking problem) at the time of data collection were excluded.

Sample size determination and sampling procedure
The sample size (n) required for this study was determined using single population proportion formula (n = (Zα/2) 2 p (1-p)/d 2 )); where n = the required minimum and feasible sample size, Za/2(1.96): significance level at α =0.05 with 95% confidence interval, p: proportion of substance use in Mekelle University (21%) [18], and d: margin of error (5%). The calculated sample size was 255. However, the study population (N = 2500) was less than 10,000 and hence the correction formula was used to calculate the exact sample size (n f ). Therefore, the final required sample size was 254 by considering a non-response rate of 10%. Stratified sampling method followed by simple random technique was used to select individual students that were to be included in the sample. Using a stratified sampling method, the total number of students in the college was first divided into different strata based on their departments. Then each department students were again grouped into other different strata depending on class year (batch). Finally, a simple random sampling technique was used to sample students from each departmental batch by using a student's rosters as a sampling frame. Eligible students were directly approached by the data collectors while they were at their respective classes in morning time immediately after class attendance. The flow diagram to illustrate how 254 eligible students were approached out of 2500 is described in Fig. 1.

Measurement and data collection procedure
Data were collected using a structured self-administrable anonymous questionnaire prepared in English that contained open and closed-ended questions which included information of socio-demographic characteristics, prevalence, associated factors and health consequences of substance use. Data were collected by 8 BSC Nurses and supervised by 2 MSc health officers.

Data quality control
The data quality was assured by different methods. A structured questionnaire adapted from WHO students' drug use survey questionnaire [22,23] based on own specific objectives was used (Additional file 1). The questionnaire was validated by pretesting upon 13 (5% of the sample size) sample health science students of other nearby university (Jigjiga University). Two days of training was provided to the data collectors and supervisors on the data collection tool and the data collection procedures. Findings from the pretesting were utilized for modifying and adjustment of the instrument. For the daily activities, data collectors were supervised closely by the supervisors and the principal investigator. Completeness of each questionnaire was checked by the principal investigator and the supervisors on a daily basis.

Operational definition Ever substance user
A respondent who used the substance even once in his /her life [1,6,18,24,25,27].

Current substance user
A respondent who used substance at least once in the past most recent 30 days [1,2,6,18].

Data processing and analysis
After collection of the data, each questionnaire was thoroughly reviewed for completeness and consistency by the data collectors, supervisor and principal investigator. Then, the data were coded and entered into Epi data version 3.1 and analyzed by using SPSS for window version 23. Descriptive statistical analysis was used to examine findings of the study using frequency, mean, and proportion. The results were presented using figures, tables and text form. Bivariable analysis was carried out using the chi-square test to examine the association between substance use and associated factors. In doing so, a P-value of 0.05 or less was used as cut off level for statistical significance at degree of freedom = 1.

Socio-demographic characteristics of respondents
Though it was aimed to collect data on the calculated 254 sample of eligible students, 3 students (2 medical and 1 Pharmacy) didn't answer more than half of the questions in their respective self administered questionnaires making a response rate of 98.8%. Majority of the  Table 2). Sixty-eight (63.6%) of the ever chewers were practicing coffee drinking whereas 40(37.4%) of them cigarette smoking and 22(19.3%) alcohol drinking along with their chewing habit. Other substances (hashish, cocaine, cannabis, etc.) were asked but none of these substances were reported to be used.
Among 114 ever substance users, 80(70.2%) were found to be current substance users and 72 (87.8%) of whom were males. Among the total of 80 current substance users, current chewers account for the highest percentage [75(93.8%)] (Table 3). Most respondents [146 (86.4%)] were able to easily access and use the substance of their choice even in their dormitory rooms.
Most of the ever substance users [51(47.6%)] used substance once a day. It was found that nearly half of the ever substance users [47(44%)] practiced using substance for more than 4 years duration. Majority of the substance users cost 15-25 Ethiopian birr per day to use substances ( Table 4).

Time of starting substance use and their plan when to stop
Regarding the initiation time of substance use, the majority [111(97.4%)] started using substances after 15 years of old. About 49% of the ever substance users started using substance before joining university whereas nearly 51% of them after joining university. Out of those 49% students who started substance use before joining university, the most majority [23(20.2%)] began substance use at preparatory school whereas from those students who started substance use after joining university (51%), being freshman (32.5%) was found to be a critical time to initiate substance use at university (  (Table 6). Regarding sexual risk behavior among ever substance using students, 15 (68.2%) of the respondents had multiple sexual partners, 13 (59.1%) used condom irregularly, and 6 (27.2%) had sex with commercial sex workers. From the study, it was also resulted that among 114 ever substance users, 46(40.4%) ever had social and economic difficulties from their substance use. Among these, 43 (93.5%) had difficulties in covering monthly expenditure, 20 (43.5%) had an objection from family members due to financial inadequacy, 8   Factors associated with substance use among students In this study, based on the cross tabulation, sex, having sexual risk behavior, monthly income and family history of substance use were found to be significantly associated with substance use among students as evidenced by X 2 values of 19.67, 28.99, 72.28 and 139.72 with Pvalue of 0.05 respectively. Students' sex was one of the factors which was significantly associated with substance use in the study area. Male students were twenty times more likely to be substance user than female students (X 2 = 19.67 at Pvalue of 0.05). Similarly, those students who have sexual risk behavior were twenty-nine times more likely to be substance user than students who had no sexual risk behavior (X 2 = 28.99 at Pvalue of 0.05). Regarding monthly income and family history of substance use, students who had monthly income more than 540 Ethiopian birr were seventy-two times more likely to be substance user than students who earned a monthly income less than 540 Ethiopian birr (X 2 = 72.28 at Pvalue of 0.05). Likewise, students who had a family history of substance use were one hundred forty times more likely   to be substance user than students who had no family history of substance use (X 2 = 139.72 at Pvalue of 0.05) ( Table 7).

Discussion
One of the targets in the health goal of the sustainable development goals (SDGs) is to strengthen the prevention and treatment of substance use, including narcotic drug use and harmful use of alcohol. Therefore, this study is aimed to show the prevalence and associated factors of substance use in the study area after the launch of SDG by 2015 that involves the implementation of different preventive and therapeutic measures. Prevalence of ever substance use for at least one substance was found to be 45.5%. This finding is almost consistent with a study in many African universities which was 69.8% [6] but higher than Ethiopian studies at Mekelle University (21%), Debre markos Poly Technique College (14.1%), Hosana Health Science College (27%) and Jimma University (12.4%) [3,18,19,21]. This discrepancy may be due to a smaller sample size that was considered for this study and differences in geographic location (khat is much more cultivated and marketed nearby this study area than elsewhere in Ethiopia   [21]. This significant discrepancy in the prevalence of sexual risk behavior might be due to the difference in cultural background between the two study areas. Furthermore, a smaller sample size of this study might have contributed to this variation.

Conclusions
As compared to other studies, this study showed a higher magnitude of ever substance use and majority of whom are still using substance. This indicates the number of youngsters being involved in this practice is increasing despite the different preventive and therapeutic interventions that have been taken into action since 2015. Male sex, sexual risk behavior, average monthly income and family history of substance use were significantly associated with increased odds of ever substance use. The study also found that the leading reason for substance use was to keep alert while studying followed by psychological stress, peer pressure, role modeling of families and teachers, socialization purpose and lack of adequate recreational activities. Since all of these reasons are modifiable, every health preventive, promotive and rehabilitative action can be considered of paramount significance. Therefore, families and teachers should be role models in disliking substance use. Moreover, freshman students should be told and oriented of better stress coping mechanisms so that they can adapt themselves to the new university environment. Lastly, the authors would like to extend their recommendation to the college of health and medical science itself to expand more recreational activities so that students can prefer these services instead of substance use during their break time.
Strength and limitation of the study As this study focused on undergraduate health science students, the findings would be helpful to initiate effective substance use control programs in health science schools. Likewise, it can also be used as a blueprint to conduct an interventional study in the particular area. However, it was not possible to establish a temporal relationship between the exposure and outcome variable as this study design was a cross-sectional study. The result may not be representative of entire university students in Ethiopia due to a small sample size of the study.
Additional file 1: Questionnaire A structured questionnaire used for interviewing selected health and medical science students of HU, 2018.