Factors affecting current khat chewing among male adults 15–59 years in Ethiopia, 2016: a multi-level analysis from Ethiopian Demographic Health Survey

Background Regular khat chewing causes gingivitis, tooth loss, gastric disorders, cardiac complications, male impotence, sleeplessness, and several mental health problems. Based on the Ethiopian Demographic and Health Survey (EDHS) 2016, 12% of women and 27% of men have reported having ever chewed khat. Even though khat addiction is a major public health problem, studies that consider both individual level and community level factors are limited. Therefore, this study aimed to determine the prevalence and factors affecting current khat chewing among male adults in Ethiopia. Methods Data from EDHS, a community-based cross-sectional study conducted from January 18, 2016, to June 27, 2016, was used. A multistage stratified cluster sampling technique was used to select participants. Both descriptive and analytical statistics were done. Bi-variable and multivariable multilevel logistic regression analyses were performed to determine factors affecting current khat chewing. Adjusted Odds ratio (AOR) with 95% Confidence Interval (CI) for variables with P-value < 0.05 was used as a measure of association. Result A total of 12,595 male adults were included. The prevalence of current khat chewing was 23.61% (95% CI: 22.87, 24.36). Age 20–24 years; (AOR = 2.68, 95% CI: 2.02, 3.56), being uneducated (AOR = 1.62, 95% CI: 1.10, 2.39), professional/technical/managerial job (AOR = 3.59, 95% CI: 2.18, 5.91), Muslim religion (AOR = 18.30, 95% CI: 13.54, 24.74), poorest wealth index (AOR = 0.67, 95% CI: 0.51, 0.89), being divorced (AOR = 0.38, 95% CI: 0.21, 0.69), history of alcohol drinking in the last 30 days (AOR = 2.15, 95% CI: 1.69, 2.73), and history of cigarette smoking in the last 30 days (AOR = 14.92, 95% CI: 10.88, 20.47), and Amhara region (AOR = 0.07, 95% CI: 0.04, 0.14) were significantly associated with khat chewing. Conclusion Khat chewing remains high in Ethiopia with certain regional variations. The uneducated, older age, Alcohol and cigarette users, Muslims, and professional workers were at higher risk of khat chewing whereas the poorest wealth index and being divorced reduced its risk. Policymakers should consider a multi-faceted policy approach that accounts for regional variation and the identified risk factors to alleviate the problem.


Background
Khat, native to Ethiopia, and the southern Arabian Peninsula is an evergreen shrub cultivated as a bush or small tree [1]. Its young buds and tender leaves (the main utilized part) contain amphetamine-like psychoactive substances, which produce euphoria and stimulation [2]. People chew khat for a variety of reasons, these include entertainment, as part of social events, to spend time, as a culture and some also use it to stay active when studying [3].
High prevalence of khat chewing has been recorded in Yemen and the Jazan region of Saudi Arabia. According to global synthetic drug assessment in 2014, the prevalence of khat chewing among people aged 16 and above in Yemen was 52% [13]. In the last several years, khat has been increasingly transported from East Africa including (Ethiopia, Kenya, and Uganda) and the Arabian Peninsula (Yemen) to other regions [14]. A large amount of khat is smuggled from Ethiopia and Kenya to the United Kingdom and the Netherlands by plane, where until recently it has not been under national control in either of the countries [15].
Globally, in different countries khat and its consumption has been regulated by the Government [24]. In Ethiopia, especially in the Amhara region, the regional government imposed policy and increased taxation. But the problem remains high and evidence that shows the determinants of khat chewing especially that entertain both individual level and community level factors are limited. Multilevel models can be used to draw individual-level inferences, but inferences can also be made regarding group-to-group variation, including whether it exists in the data, and the extent to which it is accounted for by group and individual-level characteristics [25]. Therefore, this study was aimed to assess the predisposing factors of khat chewing among male adults in Ethiopia.

Study design and setting
Data from EDHS 2016 was used. EDHS 2016 is a community-based cross-sectional study conducted from January 18, 2016, to June 27, 2016. Ethiopia is situated in the Horn of Africa between 3 and 15 degrees north latitude and 33 and 48 degrees east longitude. Administratively Ethiopia has nine regional states. Namely: Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations Nationalities and peoples Region (SNNPR), Gambella, and Harari. In addition, it has two city administrations, Addis Ababa and Dire-Dawa. More than 82% of the country's total population lives in the regional states of Amhara, Oromia, and SNNPR [11].
Population, sample size, and sampling technique All men from 15 to 59 years in Ethiopia were the source population. Whereas, all men age 15-59 years in the selected enumeration areas (EAs) were the study population. All men age 15-59 who were the members of the selected households and those who spent the night before the survey in the selected households were included in the study.
The 2016 EDHS used a two-stage stratified cluster sampling technique with regions and residence as strata were used. Primarily, all nine regions were stratified into urban and rural clusters. A total of 654 EAs (202 urban and 443 rural clusters) were selected proportional to EA size. In the second stage of selection, a fixed number of 28 households per cluster were selected from the newly updated listing of households. Altogether, 16,650 households and 12,688 men aged 15-59 years were interviewed in the survey.

Study variables
Current khat chewing status, the outcome variable in this study was defined khat chewing within 30 days prior to the data collection period. The independent variables were grossly classified into socio-demographic and economic factors: age, religion, marital status, educational status, place of residence, region, and behavioral factors: alcohol drinking and smoking, and source of information: reading news-paper, reading magazines, and watching television.
Wealth ranking was grossly categorized into 5 major quintiles based on household assets as lowest (poorest), second (poorer), middle (middle), fourth (richer), and highest (richest). Substance use: was defined as the use of one or more of the substance like khat, Alcohol, using any type of tobacco (shisha or Gaya).

Data collection tool and procedure
The data was taken from EDHS which is collected by trained data collectors using standardized, structured, and pre-tested questionnaires. The questionnaire, based on the DHS Program's standard Demographic and Health Survey questionnaires, were adapted to reflect the population and health issues relevant to Ethiopia. The input was solicited from various stakeholders representing government ministries and agencies, nongovernmental organizations, and international donors. After all, questionnaires were finalized in English, they were translated into local languages. Raw data collected from all part of the country on Men whose age was between 15 and 59 were extracted for the analysis.
Data processing and analysis STATA version 14 was used for data analysis. Both descriptive and analytical analysis was done and presented using tables and texts. Bi-variable and multivariable multi-level logistic regressions were performed to determine the existing association among individual and community factors. Initially, a bi-variable analysis was performed and variables with a p-value of less than 0.2 were used for further analysis in the multivariable multilevel logistic regression. At the same time, Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with their corresponding confidence intervals (CI) were determined for the bi-variate and multi-variable analysis, respectively. The presence or absence of multi-collinearity was checked using the Variance Inflation Factor (VIF). Finally, p-value < 0.05 was used to declare the significance of association in the multi-variable model. The need for multi-level multivariable analysis which considers community-level factors was tested using the intra-class correlation coefficient (ICC) and models were compared using the deviance tests. The model with the lowest deviance was selected as the best-fitted model. In addition, sensitivity and specificity tests were checked. The presence and absence of univariate and multivariate outliers were checked.

Result
Baseline characteristics of study participants A total of 12,595 participants were included in the study. The mean age of the respondents was 30.7 (SD = 11.5). One-fifths, 2572 (20.4%) of participants were in the age of 15-19 years. The majority of the participants, 10,099 (80.2%) were from rural and 5876 (46.7%) had primary education. More than half, 6968 (55.3%), of participants, were married (Table 1).

The multilevel mixed-effects binary logistic regression model
The need for the multilevel model was confirmed by ICC of 66% with 95% CI (61.8, 70%). We have also compared the four models (Null model, Individual-level, community level and a model with both individual and community-level factors) and we have found the last model with the lowest deviance to be the best-fitted model ( Table 2).

Factors affecting current khat chewing among male adults in Ethiopia
In the bi-variable multilevel logistic regression analysis; age, sex of household head, residence, educational status, occupation, religion, wealth Index, current marital status, alcohol drinking history in the last 30 days, cigarette smoking history in the last 30 days, and region were associated factors with khat chewing with a p-value < 0.2.
In the multivariable analysis Age, educational status, occupation, religion, wealth index, current marital status, alcohol drinking history in the last 30 days, cigarette smoking history in the last 30 days, and region were significantly associated with current khat chewing at a pvalue < 0.05. The odds of khat chewing among older adults were higher than that of teenagers aged between 15 and 19 years. When compared to adults who had higher educational status those who had no education (AOR = 1.62, 95% CI: 1.10, 2.39) and primary education (AOR = 1.85, 95% CI: . 30 (Table 3).

Discussion
The study determined the prevalence of current khat chewing status and factors affecting it among male adults of Ethiopia. A range of different sociodemographic and economic factors affecting current khat chewing was identified, these include Older age, being uneducated, Muslim religion follower, poorest wealth index, being divorce, history of alcohol drinking for the last 30 days, history of cigarette smoking for the last 1 month, and regions of Harari and Dire Dawa had statistically significant association with khat chewing. Older people had higher odds of being a khat chewer as compared to teenagers. This finding is in line with other studies conducted in different institutions in Ethiopia [1,2] and a community-based study on EDHS 2011 [26]. The possible reason could be young people tend to be under family control which reduces their risk of exposure. As a result, their probability of chewing will be less.
Lower educational status was found to be a significant independent predictor of current khat chewing. This finding is in contrast with a study conducted in Butajira, Ethiopia [13]. But, the current study was in agreement with a study conducted from the Jazan region, Saudi Arabia, which showed that illiterates were at higher odds of chewing khat [23]. The reason could be uneducated men would have a lack of information on the negative consequences of khat on their health [27]. Therefore, they would continue khat chewing.
The type of occupation was associated with khat chewing. Accordingly, professionals, clerical, sales, agricultural, service, skilled manual, and unskilled manual workers were at higher odds of being khat chewer. This finding is in line with a study conducted in Ethiopia [26]. This could be due to the fact that jobless individuals cannot afford to buy khat and also they have relatively less work which will stress them so as to need such stimulants. In this study, Muslims were at higher risk of being khat chewer when compared to Orthodox Christians whereas being Catholic and Protestant was found to decrease the odds of chewing khat. This finding is in line with other studies from Ethiopia [1,12,13,28]. This could be traditionally Muslim religious followers have good acceptance to gain maximum concentration while doing their work and prayer [27,29].
The odds of khat chewing among poor people were reduced by 33% compared to those with the poorest wealth index. This finding is in agreement with a community-based study from EDHS 2011 [26]. This could be because the poorest people could not even afford basic necessities like food and unable to cover the expense of khat [30].
Divorced men were associated with lower odds of Khat chewing than their single counterparts. This finding is in contrast with a study conducted in Ethiopia [26]. The lower odds of khat chewing among divorced people could be their tendency to modify their lifestyle after divorce as this khat chewing could be also a reason for the divorce. Single individuals usually are also young people who are under family control.
In this study, alcohol drinking is associated with an increased risk of khat chewing as compared to their counterparts. This result is consistent with a systematic review and meta-analysis [31]. A similar association was found from the study conducted in Butajira [13], Saudi Arabia [6], and Uganda [32]. This could be due to the fact that khat chewing causes sleep disturbance [33] as a result, chewers would use alcohol for better sleep. However, different studies showed concurrent use of khat, cigarette, and alcohol would result in sleep deprivation [32,34,35]. Therefore, giving due attention is needed to minimize the concurrent effect of khat, alcohol, and cigarette smoking.
Community-level factors of khat chewing were also determined and the region was significantly associated with khat chewing. Men living in the regions of Harari and Dire Dawa were at higher odds of khat chewing. This finding is in line with a study conducted in Ethiopia [26]. This due to the cultural difference across the regions and especially khat chewing in the Eastern part of Ethiopia is culturally acceptable and is considered as a good practice.
This study has a significant implication for the public and policymakers. Khat chewing in the community could affect social life [24], the economy [27], and result in poor health outcomes [35][36][37][38]. Currently, in Ethiopia farmers in the rural area are expanding the cultivation of khat and the landmass covered by cereals and fruits is decreasing from time to time. However, the negative effect of khat on health outweighs the income earned from khat production and sale. In addition, khat chewers are prone to poor appetite and resulted in malnutrition. Khat chewing is also a growing concern among Ethiopian universities [39] associated with low academic performance in Ethiopian students [40][41][42]. Khat chewing contributes to the high burden of non-communicable diseases like cardiovascular disorders [43,44]. Khat increases the concurrent use of cigarettes and increases risky sexual behavior [9] which further increases the burden of the Human Immune Deficiency Virus (HIV). Khat mainly affects the productive population of a country like university students, youths, and employers this will affect the country's economy at large in the long run. Therefore, policymakers should design strategies on khat sale and production including high taxation or banning to minimize the burden.

Limitations
Since the study was cross-sectional it does not show the temporal relationship between the outcome status and the risk factors. Important variables like peer pressure and perceptions/attitude on benefit, consequence, duration of chewing, dosage and frequency were not addressed in this study. So, the long term implications of khat were not studied in this study. However, the authors tried to determine the causes of khat chewing in Ethiopia among the men population.

Conclusion
Older age, being uneducated, Muslim religion follower, poorest wealth index, being divorce, history of alcohol drinking for the last 30 days, history of cigarette smoking for the last 1 month, and regions of Harari and Dire Dawa had a statistically significant association with khat chewing. Therefore, to effectively control khat chewing among the diverse communities in Ethiopia, policymakers should consider a multi-faceted policy approach that accounts for regional variation, the local social contexts, as well as the complementary nature of smoking and khat chewing practices.