Khat chewing among Ethiopian University Students- a growing concern

Khat is a plant with amphetamine like characteristics with effects including insomnia, euphoria, decreased fatigue and suppressed appetite when chewed [1]. Frequent and chronic khat use has been associated with various consequences. These include substance dependency [2], early sexual debut [3] unprotected sex [4] mental health issues [5, 6] and with various social, cognitive and financial problems [7‐10].

Ethiopia is one of several countries in Africa and the Middle East where khat chewing is common. A national study reported 23.0% of out-of-school and 7.5% of in-school adolescents use khat [4]. A separate study estimated prevalence of khat use in the general population of Ethiopia was 27.3% among men and 11.0% among women of 15–49 years in 2011 [11].

Khat is consumed by students when they wish to study for long hours especially during examination periods [12]. In Ethiopia there have been few studies of khat use among university students. The available studies were either done before the expansion of public universities and increased admission loads or represent only a single faculty/department of a university which might affect estimation of khat use among university students. The study conducted in 2002 among Gondar School of Medical Science and Bahir Dar polytechnic - and Pedagogy Colleges reveled a prevalence of 17.5% [13]. This study was conducted before universities expanded to the current level as explained later on. Other, more recent studies, reported prevalence of 14.4% from a study done on technology and pharmacy faculties of Addis Ababa University [14]; 2.3% among Medical faculty students of Addis Ababa University [15]; 6.3% from Debremarkos polytechnic college [16]; 27.9% from Axum University [17]; and 12.9% from private and public colleges in Bahir Dar city [18].

Socio-demographic characteristics such as being male, having pee r influence and student seniority have been associated with khat chewing [19‐21]. The most common reasons g ven for chewing khat include: staying alert and achieving better concentration at work; increasing motivation when there is a need to work long hours; socializing; and other recreational purposes [13, 22].

Ethiopia has markedly expanded the number and admission capacity of public universities in the last decades. The numbers of public universities under the Federal Ministry of Education (MoE) have increased from less than ten in 2004/2005 academic year to thirty-one in 2013/2014. Currently four additional universities are in line to join these universities [23]. This expansion has also changed the diversity of students. Different regions and cultural groups are better represented. Undergraduate students are assigned to public universities from all over the country by the Ministry of Education of Ethiopia (MoE). Due to this process students at public universities in Ethiopia are composed of different ethnic and cultural backgrounds.

Knowing the prevalence and reasons for khat chewing among university students is important because of its serious health, social and economic consequences. Khat use among university students in Ethiopia has been studied as early as 1988 [24]. However recently the diversity of university students have changed following expansion of higher education in Ethiopia. In addition most recent studies on khat use among Ethiopian university students were done on single faculties or departments, which may not represent the whole university student community. Those factors outside of the university campus, such as living arrangements, that may affect students’ khat use are not well documented. Therefore, this study was designed to assess the prevalence and reasons for khat chewing among university students in the current context of university setups using representative sample size from Bahir Dar University.

A total of 3,872 students were invited to participate in the study and of which 3,268 completed and returned the self-administered questionnaire. Of those, 3,001 questionnaires were completely filled and included for analysis in this paper. Thus, the overall response rate was 77.5%. The majority of respondent were male (77.6%), Orthodox Christians (81.8%), living on campus (96.1%) (Table 1).The overall prevalence of lifetime khat use is 24.0% (95% CI: 22.5%, 25.6%). Current use of khat is reported by 12.7% (95% CI: 11.5%-13.9%) of students. The prevalence of habitual khat use is reported by 4.8% (95% CI: 4.0%, 5.6%). Khat chewing occurs more frequently among male students than females in all categories (Figure 1).

An Adjusted Odds Ratio (AOR) was calculated to various factors that are likely to be associated with ever, current (chewing in the current academic year) and habitual khat use (Table 2). Male students were more likely to chew khat in the current academic year as compared to female students [AOR = 3.3 (95% CI: 1.8, 6.0)]. Students who perceive that khat helps to study better were more than 6 times more likely to chew khat in the current academic year as compared to those who do not [AOR = 6.6 (95% CI: 4.6, 9.5)]. Students who live in off campus housing were 3 times more likely to chew khat in the current academic year as compared to those students who reside on campus [AOR = 3.0 (95% CI: 1.5, 6.0)]. Students were more likely to chew khat if they have close friends who are khat chewers compared to those who do not have friends who chew khat at all [AOR = 4.2 (95% CI: 2.6, 6.9)]. IStudents that reported family history of khat chewing were more likely to chew khat than students who reported no family history of khat use [AOR = 2.8 (1.9, 4.2)]. These factors were found to be cross-cutting factors across the three categories of khat use (Table 2).

About a fourth of university students, 24.0%, have ever chewed khat, and about 1 in 8 reported chewing khat during the academic year in which the study was conducted. Male students were more likely to chew khat. Students living in off campus housing, those having a chewer friend, and those having a positive perception of khat benefits for studying well were also more likely to use khat.

This study provides a more accurate prevalence of khat use as compared to most of the recent studies on khat use among university students in Ethiopia. This study has much larger sample size which represent all the undergraduate students compared to previous studies conducted among University students in Ethiopia [13, 15]. In addition, male and female students were selected for the study proportionally considering the actual male to female student ratio at Bahir Dar University during the study period thus avoiding representation bias.

Majority of the non-response rate in this study was accounted for by the absence of the students in the graduating class who left the campus for internships off campus during the study period. The absence of the students is likely to underestimate the prevalence of khat use. Due to this non-response, we might not have detected the actual difference of khat use across study years. Previous study on university students of Ethiopia has shown an increase combined prevalence of khat use and cigarette smoking [13]. Studies elsewhere have shown increased prevalence of substance use among college students as year of study increases [26].

The current study has reported a 24.0% lifetime use of khat which is similar to previously reported lifetime prevalence in 2002 [13]. However, recent use of khat measured during the four-week data collection period was different from 17.5% in 2002 [13] to 7.7% in this study. Another study done among Addis Ababa University Medical students reported four week khat use prevalence of 3.7%, which is lower than the 2002 report [15] as well as the current study. Current reports of lower khat use among university students may not be a real decline but due to change in social and demographic diversity of students that followed the wide expansion of higher education in Ethiopia after 2002 [27]. Another explanation is the various definitions used to define current use may have caused the difference. Some of the studies done on khat use among university students didn’t establish clear definitions of current khat use [14, 15, 18].

In this study, prevalence of khat chewingwas higher among male students when measured across different time periods. This is consistent with several studies conducted among higher learning institutions in Ethiopia and elsewhere [13, 15, 20, 21, 28]. Substance use is mediated by gender identities. Patriarchal societies accept substance use among men more easily than substance use among women allowing men to use substances more than women [29, 30]. Men have also more opportunities for substance use putting them at higher risk [26].

This study showed that students who have close friends who chew khat are more likely to use khat. Previous evidences have similar association with khat chewing and friends’ khat use [13, 15]. Khat chewing usually starts during adolescence period and is introduced by friends and peers [31, 32]. Other substance use studies have documented that the closeness of friendship as well as the level of friends’ influence are strong indicators of substance use among young people [33, 34].

Family history of khat use is associated with current khat use by students in this study. This is consistent with previous studies which reported association between family history and khat use [13, 15, 35]. This could be due to acceptance of khat use as normative behavior by students whose family members use khat.

Students who reside in off campus accommodation are more likely to be current and habitual chewers. This could be as a result of students’ choice of living with other students who have similar interests together exposing them to peer influence [33]. Off campus accommodation is a choice made by individual students. Students with particular characteristics and behavior may choose to live together. This arrangement could be a proximal indicator of students’ higher risk of khat and other substance use [36].

Expectation of khat to help students study was the strongest predictor for khat use in this study. The main reason given for chewing khat by students is to concentrate and study well [13, 15]. This is similar to other substance use studies among university students where expectation of substance to enhance academic performance have been associated with use [37‐39]. Studies that examine the association between khat use cognitive response and learning had reported an opposing finding to the positive expectation [10]. Khat has been linked with diminished cognitive capacity and poor academic performance. Khat chewing university students in Ethiopia were found to have a lower mean Cumulative Grade Point Average (CGPA) as compared to non-chewer students [40]. Poorer academic performance was also documented in students in Saudi Arabia [41]. While there has been no evidence that khat affects already stored knowledge, there is evidence that shows its interference in active learning while using it [10]. A study on methamphetamine, use has shown similar relationship between learning and use, where learning is affected once an individual starts using the substance [42]. Khat has similar effects with amphetamine [43, 44], which is in turn has weaker, but similar, effect to methamphetamine [45].

This study has shown that khat use is closely associated with students’ contextual environment and expectation of khat. The finding that students have positive expectation of khat for their academic performance conflicts with existing evidences of negative effects of khat on academic performance. This study has also identified that khat use among university students is highly influenced by peer and family khat use.