Psychoactive substance use among undergraduate students of Mizan-Tepi University in Southwest Ethiopia

Abstract Students’ use of psychoactive substances is a significant public health issue around the world. Therefore, this study aimed to assess the prevalence, associated factors, and related problems of psychoactive substance use among undergraduate students at Mizan-Tepi University in Ethiopia. A cross-sectional study was conducted among 544 regular undergraduate students. The data were collected using a pre-tested self-administered structured questionnaire. The data analysis was done using SPSS version 21. The level of significance in the multivariable logistic regression analysis was declared at a p-value <0.05. Of the 544 respondents interviewed, the lifetime and current prevalence of psychoactive substance use among undergraduate students was 62.5% and 27.9% respectively. The factors associated with current psychoactive substance use were being male (AOR = 3.01, 95% CI [1.64–5.53]), being Muslim (AOR = 3.13, 95% CI [1.64–5.96]), from urban residence (AOR = 3.12, 95% CI [3.01–5.31]), having divorced/separated parents (AOR = 3.08, 95% CI [1.64–5.79]), having family substance use (AOR = 7.98, 95% CI [5.52–11.6]) and peer substance use (AOR = 4.33, 95% CI [2.68–7.26]). Of the 332 reported substance-related problems, 96 (28.9%) had oral/gastric problems followed by frequent loss of appetite (78, 23.5%). The current prevalence of psychoactive substance use was substantially higher than in other studies in Ethiopia. The study also found that sociodemographic, familial and peer factors were factors associated with psychoactive substance use. Therefore, higher education institutions should consider designing programs to control substance use among students to improve student health and academic performance.


Introduction
Substances that contain psychoactive properties do not necessarily lead to addiction or dependence (Njoroge, 2017).Psychoactive substance use, such as drinking alcohol, cigarette smoking, khat chewing, cannabis use, and illicit drugs, is a public health concern among youth worldwide (Kahsay et al., 2019;World drug Report, 2013) with an estimated 167-315 million people between the ages of 15-64 using substances globally (World drug Report, 2013).
The problem of psychoactive substance use involves all age levels but appears to be more dangerous and common in adolescence and young adults (Clowdus, 2016;Nižić et al., 2013;Tshitangano & Tosin, 2016;Webb et al., 1996).It affects health, impairs life, and is the main source of crime (Essien, 2010;Kounenou, 2010).It has become one of the most serious and rapidly growing phenomena, producing many terrible impacts on health, behavior, and the country's economy globally (Alebachew et al., 2019;Gaete et al., 2018;Odejide, 2006;Rabie et al., 2020), a particularly high burden in developing countries (Osman et al., 2016).
Young people in universities and learning institutions are a particularly exposed group to psychoactive substance use (Teferra, 2018;World Health Organization, 2018).University students may have higher prevalence than the general population (Yeshigeta et al., 2009).It has been said that university life, particularly the early years, is a "transitional" time when students transition from a constrained high school life, which is largely monitored by parents, to a more independent life that may be easily influenced by a liberal campus atmosphere (Bunch, 2002;Olley, 2008).This exposes students to a wide range of experiences, practices and choices, which may increase the risk of psychoactive substance use among university students (Bunch, 2002).
Worldwide, psychoactive substance use among undergraduate students is a major public health problem and over 29 million people suffer from substance-related disorders (Duru et al., 2017).University students are an at-risk population for psychoactive substance-related problems (Simons et al., 2005), which negatively affect students' academic performance (Mekonen et al., 2017) and harm their mental health (Yeshigeta et al., 2009).
The factors associated with psychoactive substance use are varied and may include age, gender, religion, marital status, level of study, feeding out of the university café, being from a private preparatory school, getting higher monthly pocket money, parents' educational level, low family income, the status of parents' union, family substance use, peer substance use, easy accessibility of substance, the demise of either or both parents, living without parents and depression (Ageb et al., 2019;Cranford et al., 2009;Duru et al., 2017;Fareo, 2012;Gebremariam et al., 2018;Htet et al., 2020;Kabir et al., 2016;Rabie et al., 2020;Shahabuddin et al., 2017;Tesfaye et al., 2014;Tsegay & Esmael, 2014;Wagner et al., 2007).The use of psychoactive substances is a growing concern in Ethiopia.In a particular college and university students are the most at risk of psychoactive substance use (Tesfaye et al., 2014), and their impacts on the younger generation have become a serious concern (Ageb et al., 2019;Roba et al., 2019).
A systematic review and meta-analysis study in Ethiopia showed that the prevalence of overall current psychoactive substance use among university students was 36.24%;alcohol (25.27%), khat (17.3%), and cigarettes (9.8%) (Roba et al., 2021).Despite the evidence available regarding psychoactive substance use, the problem is not well studied among these groups of the population in the study area.Therefore, this study aimed to assess the prevalence, associated factors, and related problems of psychoactive substance use among undergraduate students at Mizan-Tepi University in Ethiopia.

Study design, area, and period
A cross-sectional study was conducted among 544 undergraduate students at Mizan-Tepi University (MTU) in southwest Ethiopia from June 1-30, 2018.Mizan-Tepi University was established in 2006 and has three campuses (Mizan, Aman and Tepi campus).The study was conducted on the Tepi campus, which is found in Tepi town, sheka zone at 611 km and 881 km southwest of Addis Ababa, the capital city of Ethiopia, and Hawassa, the capital city of South Nations, Nationalities, and Peoples Region (SNNPR) respectively.The campus has two colleges, one school, and 15 departments.During this study, 9562 students attended the Tepi campus.

Populations
All regular students of the Tepi campus, Mizan-Tepi University during data collection were the source population.All randomly selected students who studied at the Tepi campus were the study population.

Sample size determination and sampling techniques
The sample size was determined using a single population proportion formula with the assumption of the prevalence of substance used to be 62.4% (Tesfaye et al., 2014), 95% confidence interval, 5% margin of error, 10 % for non-response rate, and 1.5 design effect.The final sample size was 595.Multi-stage stratified sampling technique was used.First, the total sample size was proportionally allocated to colleges/schools and departments accordingly.Then, each department's proportional sample size was allocated at each year level (batch).Finally, a simple random sampling technique was used to select participants in each batch.

Study variables
The dependent variable was substance use (khat/alcohol/cigarette).The independent variables were age, sex, religion, residence, family income, educational status of parents, condition of parents, family substance use, and peer substance use.

Operational definitions
Psychoactive substance use: the use of at least one of the following psychoactive substances (alcohol, khat, and cigarettes) to alter mood or behavior (Yosef et al., 2021).Current use: consuming any substance within the last month/30 days (Yosef et al., 2021).Lifetime use: refers to the use of any substance at least once in an individual's lifetime (Yosef et al., 2021).Family substance use: refers to at least one family member (father, mother, or siblings) using at least one of the substances (alcohol, khat, and cigarettes).Peer substance use: groups of people of the same age, status, or interests, who use at least one substance (alcohol, khat, and cigarettes).

Data collection instruments and procedures
The data were collected using a self-administered structured questionnaire adapted from the World Health Organization (WHO) students' drug use survey questionnaire (Humeniuk et al., 2010).The questionnaire comprised socio-demographic characteristics, socio-demographic, and substance use profiles of their family, the prevalence of current and lifetime substance use, and substance use-related profiles of the respondents.It was translated from English to the local language (Amharic) and back-translated to English.Data quality was assured by properly designing and pre-testing the questionnaire.We conducted a pretest on 5% of the total sample size at Mizan-Aman Polytechnic College and made necessary adjustments based on the results of the test.Data collectors and supervisors were trained regarding the objective and data collection procedure.All methods were performed following relevant guidelines and regulations and data collection was done ethically.

Data processing and analysis
The data were checked for accuracy before being coded and entered into Epi Data Manager software and analyzed using SPSS version 21.Binary logistic regression was employed to identify the association between dependent and expected independent variables.Independent variables associated with the dependent variable at a p-value of less than 0.25 in the bivariate logistic regression model were fitted into the multivariable logistic regression model to control confounding.Multi-collinearity between independent variables in the model was checked, and the variance inflation factor (VIF) was found acceptable (less than 2).The Hosmer-Lemeshow goodness-of-fit test indicated (P = 0.341) that the model fit the data well.

Socio-demographic characteristics of the respondents
Of the 595, 544 students participated with a 91.4% response rate.The mean age of the respondents was 22 (±4.12)years.The majority (87.5%) of respondents were below 25 years old.More

Socio-demographic and substance use profiles of the family
The majority (72.4%) of parents lived together.Four hundred ninety-three (90.6%) and 158 (29%) of the families had < 5000 ETB monthly income and substance use respectively.Of 158 family substance use, 129 (81.3%) were fathers only (Table 2).

Prevalence of lifetime and current psychoactive substance use
The lifetime and current prevalence of substance use among students at Mizan-Tepi University was 62.5% and 27.9% respectively.The most common reported lifetime and current substance use was alcohol drinking at 42.6% and 23% respectively (Figure 1).

Psychoactive substance use-related profiles and related problems
Nearly three-fourths (72.4%) of respondents used substances for 2 years or more.There were 108 respondents (71.1%) who used substances at the rented house outside of the university.More than one-third (36.8%) of respondents mentioned peer influence as a reason for their current substance use.Of the 332 reported substance-related problems, 96 (28.9%) had oral/gastric problems followed by 78 (23.5%) and 58 (17.5%) had frequent loss of appetite and absenteeism in class after taking substances, respectively (Table 3).

Discussion
The general population in Ethiopia frequently uses psychoactive drugs such as khat, alcohol, and cigarettes (Haile & Lakew, 2011;Teklu et al., 1999), and studies suggest rising trends in these drug usage among university students in Ethiopia (Abdeta et al., 2017;Gebreslassie et al., 2013;Tesfaye et al., 2014).This study aimed to assess the prevalence, associated factors, and related problems of psychoactive substance use among undergraduate students at Mizan-Tepi University in Ethiopia.The prevalence of psychoactive substance use among undergraduate students was 27.9%, 95% CI (24.1%-31.7%).This finding was consistent with 31.5% in Haramaya University (Alebachew et al., 2019) and 28.6% in Wolaita Sodo University (Mekonen et al., 2017) studies in Ethiopia, 31% in Sudan (Osman et al., 2016), and 29.1% in Imo state, Nigeria (Duru et al., 2017).It was lower than 43% in Jimma University (Desta et al., 2018) and 46.3% in Debre Markos university (Tsegay & Esmael, 2014) studies in Ethiopia.But it was higher than 16.7% in Adigrat University, Ethiopia (Mossie et al., 2015), 17.5% in Nigeria (Idowu & Somefun, 2020), and 20.3% in Myanmar (Htet et al., 2020).The variation observed between the current and previous studies could be the difference in the sample size, operational definition used, and the methodology as a whole.Besides, socio-demographic, socio-economic, and lifestyle or behavioral factors differences between different population groups may create great variation.

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In this study, sex was significantly associated with substance use.Being male was 3 times more likely to use substances than being a woman.This finding was in line with several studies conducted elsewhere (Alebachew et al., 2019;Cranford et al., 2009;Duru et al., 2017;Fareo, 2012;Gebremariam et al., 2018;Htet et al., 2020;Kabir et al., 2016;Mahmood et al., 2019;Rabie et al., 2020;Shahabuddin et al., 2017;Tesfaye et al., 2014;Tsegay & Esmael, 2014;Wagner et al., 2007).This could be because males are more likely to experiment with things in their lives.The community considers female substance use taboo and male substance use not a big problem.Respondents who are Muslim were 3 times more increased odds of substance use behavior than Christians.Being Muslim was significantly associated with substance use behavior.This finding was contrary to a study done at Haramaya University, Ethiopia (Tesfaye et al., 2014).Despite this, alcohol consumption was common among Christian students.However, Muslims chew khat.This study operationalized users as users of substance by using at least one of the substances (alcohol, khat, and cigarettes).The increased prevalence of khat chewing among Muslims results in high likelihood of Muslim students being classified as substance users.This could be the reason for the variation observed between this study and the previous study in Ethiopia.
Respondents from urban residences were 3 times more likely to consume substances than those from rural areas.This finding was supported by demographic and health survey data from Ethiopia (Central Statistical Agency CSA [Ethiopia] and ICF, 2016).This could be the fact that students who come from city areas are more likely to familiarize themselves with substances (either using or observing someone who uses substances) due to the more accessibility of substances in cities than rural areas.
Respondents who had divorced or separated parents were 3 times more likely to use substances than those with parents living together.This finding was consistent with a study done in Imo State, Nigeria (Duru et al., 2017).This could be explained by those students who had divorced/separated parents who did not get parental restrictions and no one cared for them to be disciplined.Besides, those individuals are more likely to become hopeless and depressed and prone to experimenting with substances to relieve their problems.An individual who feels hopelessness or sadness and depression is more likely to use the substance (Htet et al., 2020;Mahmood et al., 2019;Tesfaye et al., 2014).
Respondents who had family members who used substances had an 8-fold higher probability of engaging in substance abuse than those who did not have a family member who used substances.Having substance-using family members was significantly associated with the respondent's substance-use behavior.This finding was consistent with previous studies elsewhere (Alebachew et al., 2019), and (Ageb et al., 2019;Fareo, 2012;Gebremariam et al., 2018;Kabir et al., 2016; Shahabuddin et al., 2017;Tesfaye et al., 2014).This could be because any behavior performed within the family may be easily followed by children.
Respondents who had substance-user peers were strongly associated with substance-use behavior.Respondents who had peer substance users were 4.3 times more likely to use substances than those who did not have a peer with substance use.This finding was in line with previous studies conducted elsewhere (Ageb et al., 2019;Gebremariam et al., 2018;Htet et al., 2020;Kabir et al., 2016;Shahabuddin et al., 2017).This could be because students may borrow or behave in a friendly manner (any behavior of a peer may greatly influence the behavior of the respondents).
In this study, the use of the psychoactive substance was associated with multiple healthrelated problems, evidenced by 63.2% had oral/gastric problems followed by 25% and 21.1% had difficulty learning and sleeping problems after taking substances respectively.This finding was supported by other studies which revealed that psychoactive substances is associated with increased risks of poor academic performance (Kassa et al., 2017), sleeping disorders (Robinson et al., 2013), and gastrointestinal disorders (Fasanmade et al., 2007;Nigussie et al., 2013).

Limitations
The authors acknowledge some limitations in this study.The study was conducted before COVID-19, and therefore does not accurately reflect the current rate of psychoactive substance use among students in the study area.The cross-sectional nature (snapshot approach to data collection) of the study design does not allow for ascertaining the cause-effect relationship between the dependent and independent variables.

Conclusion
The current prevalence of psychoactive substance use was substantially higher than in other studies in Ethiopia.The study also found that sociodemographic, familial and peer factors were factors associated with psychoactive substance use.Therefore, higher education institutions should consider designing programs to control substance use among students to improve student health and academic performance.
designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data. and