Prevalence and determinants of chewing khat among women in Ethiopia: data from Ethiopian demographic and health survey 2016

Khat (Catha edulis) is a natural stimulant widely cultivated and available in East Africa and the Middle East [1]. The biochemically active ingredients of khat are cathinone and cathine, which are alkaloid chemicals bearing resemblance to the psychoactive substance of amphetamine, both structurally and functionally [2]. Cathinone is the main psychoactive component of khat leaves and a potent stimulator of the sympathetic nervous system as well as the central nervous system, similar to the pharmacological effects of amphetamine [2]. Chewing fresh leaves of the khat tree is the most common mode of intake [3].

Khat abuse is an increasing public health problem and strongly associated with adverse mental and other outcomes and such as psychological distress, poorer quality of life and increased road traffic accident in low-income countries [4]. Across the world, an estimated 20 million people chew khat leaves daily [4]. Khat is generally used for its perceived ability to facilitate interpersonal communication in social settings, to induce euphoric and performance enhancing effects and to fend off fatigue, as well as for its perceived medicinal value for the treatment of headaches and common cold [5].

Khat use has been associated with numerous health problems. Basic research studies have found evidence of altered stress response [6], cognitive deficits [7, 8], increased levels of depressive symptoms and distress [9] and insomnia [10] in habitual khat users. Research has also shown that prolonged exposure to khat may lead to a long-lasting sensitization to the effects of other drugs [11]. In addition to physical and mental harm, much time and household income is spent on obtaining and chewing khat [12], which severely affects users’ social life and family [13]. The habit of chewing khat may be postulated as one of the risky behaviours that could fuel the spread of sexually transmitted infections (STIs) due to associated risky sexual behaviours like having casual sex, unprotected sex and early initiation of sexual activity reported among chewers [14]. Studies reveal that khat consumption may impact fetal health, for example affecting fetal growth by inhibiting utero-placental blood flow [15, 16].

Research shows that Khat use is a common practice in Ethiopia [17]. Before 2000, khat chewing by women was generally not considered acceptable [18]. Currently, however, use of khat among women is increasing very rapidly [19]. Research suggests that husbands may be in part responsible for these changes as they encourage their wives to share in the chewing of khat [18].

People who use khat are more vulnerable to khat-related problems like depressive symptoms, posttraumatic stress disorder and common mental disorder [20, 21], the issue to date has not received much attention from local authorities.

Few studies have been conducted to establish prevalence of use and associated factors, and these tended to be small and focusing on specific settings [22].

The current investigation, therefore, aimed to contribute to current knowledge on the use of khat and associated factors among women in Ethiopia, using data from the uniquely representative and population-based 2016 Ethiopian national demo-graphic and health survey (EDHS).

A total of 15,683 participants were included. The mean (SD) age of women was 27.9+ (9.2) years. The majority were Orthodox Christian by religion (40.9%), had no education (44.8%) and were from rural settings (65.9%) (Table 1). The highest proportion were from the age group 15–19 years (22.3%) followed by the 20–24 years group (18.5%) and the 25–29 years group (18.1%). A total of 24.8% of participants were identified as ‘poorest’ and 13% as ‘poorer’ according to the wealth index. The mean number of children ever born was 2.6.

The lifetime prevalence of khat chewing among women was 9.9%. The prevalence of current khat chewing was 8.4%, with a mean number of 14.2 days of use in the last month. Highest prevalence of current khat chewing was seen in the age group 40–44 years old (12.9%), 30–34 years old (12.4%), 35–39 years old (10.9%) and 45–49 years old (10.1%).

Prevalence of current khat chewing was lowest among participants from the lowest wealth index (5.9%), compared to participants from other wealth index categories. Higher prevalence of current khat chewing was also seen among individuals without education (10.3%) or only primary education (8.3%), compared to those with secondary education (4.9%) and higher education (4.6%). Among current khat chewers, the prevalence was highest among those of Muslim religion (18.2%) as compared to other religious groups (0.0–2.8%). The highest prevalence of khat chewing was seen when the relationship to the household head was wife (10.7%), and mother (10.7%), followed by head (9.5%). Prevalence of current khat use was also higher among respondents who had a single sexual partner (8.6%), two partners (8.4%) and three or more partners (8.2%), compared to those with no sexual partner (5.4%). Prevalence of khat use was similar regardless of STI in the last 12 months. The prevalence of current khat use was 8.8% in urban areas versus 8.2% in rural areas, and rates were slightly higher among those not reading newspaper/magazines (8.9% versus 5.9% of those reading these), those not listening to radio (8.7% versus 7.8% of those listening to radio), those not watching TV (8.5% versus 8.3% of those watching), and those without access to internet (8.6% versus 6.0% of those with access).

To the best of our knowledge, this was the first reported study that investigated the prevalence of khat chewing and associated factors among women in the Ethiopian population using the latest nationally representative data obtained from EDHS 2016. The findings reveal that in women, the life time prevalence of khat chewing is 9.9% versus 8.4% of current use. Multivariable analysis revealed that current use was more prevalent with higher age, having one child, lower educational level, being Muslim by religion and not pertaining to the lowest wealth index category. Protective factors were not being in marital relationship with sex partner and Protestant religion.

The prevalence of current khat use among women in this study, at 8.4%, was lower as the rate reported in Yemen (29.6%) [18]. Cultural factors underlying use may differ between the two countries, but differences may also be due to variation in survey design, and other methodological issues.

The multivariable model revealed that khat use increased with age until age 35 years, after which it remained approximately constant. This is consistent with a study conducted in eastern Ethiopia [24]. The possible reason may be that as age increases, women are more likely to have alterations in life circumstances such as bereavement, social isolation, lack of social support and financial difficulties, all of which have been found to increase the risk of substance use [25, 26]. It has also been observed that depressive symptoms may increase during the transitional phase from peri-menopause to post-menopause [27, 28], possibly driving self-medication strategies. Another reason may be that younger women tend to be more under family control, which likely reduces risk of exposure.

Not pertaining to the lowest wealth index category was associated with higher khat use rates. One obvious reason is that buying khat requires a certain level of income [29]. Furthermore, chewing khat is often developed as part of doing business in higher income groups [13]. Also, khat chewing practices affect the economic status of society due to the fact that collectively, it contributes to the loss of thousands of acres of arable land and billions of hours of work as well as utilization of scarce resources to buy khat rather than acquiring nutritious foods and care for household members [30].

Those pertaining to the religion of Islam were at higher odds to chew khat as compared to those of Orthodox religion. This is consistent with earlier work in Ethiopia [31, 32]. Chewing khat is a common practice and traditionally accepted in Islamic communities, associated with perceived benefits in concentration during work and prayer time [33, 34].

Women with lower educational status had more risk of current khat chewing compared to women with higher educational status. The current study was in agreement with a study conducted in the Jazan region, in Saudi Arabia, which showed that illiteracy was associated with higher odds of chewing khat [35]. A possible reason is that a lower level of education is associated with lack of knowledge about the negative consequences of khat use [35].

Furthermore, women who had one child had higher odds of khat chewing as compared to women without children. A possible reason is joint use under the influence of a stable partner using khat. However, this would then only apply to the period of the first child, as women with more children again had reduced risk for chewing khat. One explanation is that with an increasing number of children, less resources would be available for the khat habit.

Given that khat use among women is prevalent, and with a mean number of 14.2 days of use in the last month, information campaigns are required in order to inform the public about harmful effect of khat use [36]. For those who are affected by khat use-related disorder and comorbid conditions, treatment services should be provided. Addiction services can be offered using the existing health system. For example, primary health care may introduce routine screening and treatment for substance use [36, 37].

However, given that the majority of people do not have access to good quality of care; it is a timely need for the sustainable programs [38]. Therefore, it is a timely need for pertinent stakeholders of the Ethiopian public health care system to introduce novel approaches to generate financially sustainable programs for the early diagnosis, treatment and control of addiction through a group of well-trained health care providers.

In conclusion, the lifetime rate of chewing khat among women in Ethiopia is substantial and associated with specific sociodemographic risks. These can be used in targeted public health efforts to control increasing levels of khat use among women and reduce the associated health and economic burden.