SUBSTANCE USE PREVALENCE AMONG UNDERGRADUATE HEALTH SCIENCES STUDENTS IN ETHIOPIA: A PRELIMINARY REVIEW REPORT

Worku Abebe, PhD

Department of Oral Biology & Diagnostic Sciences

Dental College of Georgia, Augusta University

Augusta, GA 30912-1128, USA

 

SUBSTANCE USE PREVALENCE AMONG UNDERGRADUATE HEALTH SCIENCES STUDENTS IN ETHIOPIA: A PRELIMINARY REVIEW REPORT

Overview and Objective

During the past several decades, the use of mind-altering substances/drugs with abusive potentials has been recognized as a huge and growing public health problem in many countries worldwide (1).  Consistent with this, recent studies conducted in different parts of Ethiopia appear to suggest a similar trend of substance use (2). However, there is no national data that reflects the prevalence of substance use for the entire country.  Of particular concern anywhere in this regard is the greater venerability potential of the younger generation to the adverse consequences of the use of mind-altering substances. In recognition of this concern, the WHO in January of this year released a memo emphasizing the need to protect the youth of the world from the harmful effects of substance abuse. The memo further states that youth substance abuse is one of the thirteen urgent global heath challenges that need to be addressed by the international community (3).  In a previous article, this author reviewed the literature regarding the use of psychoactive substances among high school and college students (4). While some relevant information could be obtained from the review, there was a noticeable limitation in the volume and quality of the literature reviewed. In light of more recent developments and with a focus on a specific group of students, the present paper reviews the literature published during the past 10 years on the use of substances among undergraduate health sciences students attending higher learning institutions in Ethiopia.  Although preliminary, such a review is the first of its kind in Ethiopia. 

The information reviewed was based on refereed articles published during the past 10 years. Cross-sectional studies using structured self-administered questionnaires were employed in source articles that assessed substance use by the study subjects included.  

Review Findings and Discussion

The prevalence of substance use/abuse by undergraduate health sciences students in Ethiopia as reported in the literature during the past 10 years is presented in Table 1 (5-11).  The studies were conducted in wide-spread locations in the country. While only seven research papers were published during this time on this specific area, this number is relatively higher than that published in the previous 20 years. Except two papers, which documented, respectively, the use of tobacco products and cannabis and cocaine, all the rest reported the use of alcohol, khat and tobacco products variably. Although the exact reason for this variation is not clear, it may be related to such factors as geographic locations, culture and attitudes, among others, of the local communities.   

Table 1.  Substance abuse among undergraduate health sciences students in Ethiopia

References Institution Location Study year Study population (n) Overall substance use (%) Alcohol use (%) Khat use

(%)

Cigarette use (%) Other substance use (%)
Deressa W, Azazh A (10) Addis Abeba University Addis Abeba 2009 622 31.0 14.0 9.0
Eticha T, Kidane F (11) Mekelle University Mekelle 2013 193 29.5 29.5
Mossie TB et al. (8) Adigrat University  Adigrat 2014 161 16,7 8.7 6.7 6.0 Cannabis, 33.3; cocaine, 2.0
Hagos EG et al. (5) Sheba University Mekelle 2015 1076 45.5 25.1 9.2 11.4
Desta E. et al. (7) Jimma University Jimma 2015 186 48.4 16.1 26.3 5.9
Birega MG et al. (9) APTC Aman Mizan 2016 384 42,5 28 65 4.8
Alebachew W et al. (6) Haramaya

University

Haramaya 2018 254 45.4 38.6 93.9 39.5

From a broader societal perspective, each substance reported can be viewed as having its own unique position and significance (4). In most parts of Ethiopia, alcohol is a socially accepted and widely consumed substance. There is no national regulatory mechanism that monitors the production, distribution and use of alcohol in the country from a health point of view.  The substance is available as an industrial and home-made product for recreational purpose. In Ethiopia, khat (Catha edulis) is a widely grown/cultivated shrub whose fresh leaves are chewed for brain stimulation and other purposes. It is cultivated, distributed and consumed without any regulatory oversight.  Likewise, the use of tobacco products in Ethiopia is widespread. Besides being imported from outside, tobacco products are locally manufactured and made available to consumers with no restrictions. Most people consume tobacco by smoking as cigarettes. The reporting of the use of cannabis and cocaine in Ethiopia is relatively a recent phenomenon. The use prevalence of both substances is also low, and both are regarded illicit substances. Cannabis is consumed for recreational purpose as marijuana smoke. For the Ethiopian consumer, two sources of cannabis products are identified: locally grown plant and smuggled marijuana.  Cocaine has been reported to be smuggled into Ethiopia from other African countries (12).

Although the literature appears to indicate separate use of the substances mentioned, in the majority of the cases, they were consumed in combination, either sequentially or administered simultaneously all together (4). In the former case, one substance may serve as a gateway for another. For instance, khat was noted to be a gateway for tobacco and/or alcohol use. The understanding of such a practice in the use of mind-altering substances can be helpful in the delivery of more effective preventive and/or treatment programs. 

In a previous survey, it was reported that males use substances more frequently than females. In the same report, Orthodox Tewahedo followers were found to use alcohol more often than their Muslim counterparts, while the reverse was true for khat consumption. The use of alcohol, khat and tobacco products also appeared to increase with the grade levels, or ages of the students interviewed (4). 

The fact that substance use was more common among male than female students may be related to cultural reasons that may impose greater restrictions on females for such practice. The reason for the higher prevalence rate of khat use among the Muslim students could be due to their closer attachment to khat that may have its basis on religion grounds. On the other hand, more Orthodox Tewahedo Christians were identified to consume alcoholic drinks than Muslims and others, and this is suggested to be linked to a more relaxed restriction on alcohol consumption in the Christian community (4). The reporting of increased use of substances with the school grade levels or ages of students has been previously reported to be related to the stress of increased academic demand. The consideration of the different factors involved in the use of substances can add up to the pool of knowledge that may be needed to effectively combat substance abuse. In spite of the continued use of substances, many students expressed their awareness of the adverse effects of the substances and their desire to stop the harmful practices. Such an awareness and attitude on the part of the consumers can also be exploited during the formulation of educational programs against substance use/abuse (4).

The review provided variable information based on the responses of the student participants regarding factors that might be responsible for staring the use of substances and/or continuing using them once started (4). These factors included the desire to relax, to get relief from stress, to stay alert, for curiosity, for socialization, influences of other people, “addiction” to substances, influences of advisements and cultural factors. It is also worth noting that some students started using substances when they were in high schools (4). Again, taking note of these responses is important for implementing actions intended to overcome issues of substance abuse. 

The psychoactive substances reviewed here have the property of affecting the brain and behavior. There are also many more psychoactive substances that are used in Ethiopia and elsewhere.  The nonmedical use of psychoactive substances in an abusive manner is often referred to as substance/drug abuse, and this is briefly defined by the WHO as “… the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.” (13)  While such substances are taken by an abuser, most of them produce euphoria, via activation of the mesolimbic brain reward pathway, which is usually associated with tolerance and dependence/addiction with continued consumption. For many substances, depending upon a number of factors, responses linked to these mechanisms may also result in withdrawal/abstinence syndromes with abrupt discontinuation of the substances abused.  In addition to producing behavioral effects, abused substances, including those described in this review, can cause multiple acute and chronic medical/pharmacological adverse effects. For the interested reader, these effects are nicely discussed in the literature, including in the concise National Institute on Drug Abuse material posted in the link https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts (14).

As stated earlier, substance abuse has greater impact on young abusers, such as those included in this review. Recent research has shown that brain development is going during adolescence and the twenties, and various substances/drugs can affect the development and maturation of the brain (15). This in turn can impair learning ability and emotional development.  Furthermore, young adults are less likely to develop serious alcohol and other substance problems if the age of first use is delayed beyond childhood or adolescence. The implications of these findings are important for every stakeholder involved in substance abuse issues.      

Implications and Recommendations

Behavioral problems associated with the use of psychotropic substances is a progressing condition, which starts, according to the Institute of Medicine, with low risks of harm with appropriate substance use, followed by occurrence of greater risks with misuse and then significant problem with abuse of the substances (15).  In a substantial number of abusers, this may lead to addiction. The National Institute on Drug Abuse defines addiction as “… as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.  It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs” (16). Even though diagnosis was not reported in the articles reviewed here, given the conditions mentioned, it is most likely that at least a portion of the students interviewed were addicted to the substances they used. This mental state coupled with other (medical) adverse effects would have even a more devastating effect on the health of the abusers, such as impairing academic performance, and increasing the risk of accidents, homicides, suicides, and serious health issues. Beyond harming individual abusers, such adverse effects can also have broader impact on the larger student population or the general public. As such, it can have negative effects on the people around the abusers, the society at large and on the economy in various ways, among other possibilities (Figure 1). 

Figure 1. Effects of psychoactive substance abuse on health, social and economic issues.

Although the abuse of mind-altering substances is recognized to be an emerging problem in Ethiopia, only limited information is available in the literature.  However, in view of the significance of the problem, it is imperative that greater effort be made to reduce the “epidemic” of substance abuse and its devastating effects in Ethiopia. The following are some recommendations for consideration.

  • More and well-designed studies need to be conducted in order to obtain additional and more reliable information on substance use/abuse, encompassing greater geographical areas that can better represent the student population of the country
  • From current knowledge, a number of immediate actions can be taken to prevent/mitigate existing substance abuse problems,  and these actions may include: (a) educating students about the harmful effects of substance abuse; (b) providing community education on the harmful consequences of substance abuse, and members of such a community may include parents, guardians, teachers, law enforcement agents and community leaders; (c) establishing coping mechanisms to help victims of substance abuse; (d) reducing influencing factors that contribute to substance use; and  (e) formulating more effective substance use policies at institutional, community and/or governmental levels.     

As a final note, even though the situation in the USA is not directly related to the issue under consideration, it may be relevant to mention some of the on-going damaging effects of substance abuse in USA, especially in the rural population. There are reports indicating that the recent decline in the US rural population, economy and standard of living was in part due to increased mortality and morbidity caused by widespread substance abuse, particularly disproportionate use of opioids (17).  Realising the seriousness of the problem, aggressive efforts are being made by the US authorities and concerned citizens to fight back, and there are some indications of successes in this regard.   

Unfortunately, in the case of Ethiopia, it appears that no entity is clearly tasked to tackle this devastating “epidemic”.  Even worse, rather than acting as good role models for the youth, it is common to observe some high school and college instructors actively and openly engaged in the abuse of khat, tobacco and alcohol without any disciplinary or misconduct consequences (2,18,19).  Similar attitudes towards substance abuse have also been shown by some irresponsible politicians both in words and deeds. This disturbing reality calls for greater attention to be drawn not only towards the problems of the students but also towards the behaviours of the older adults holding crucial positions of responsibility.                

References

  1. United Nations general assembly resolution 67/193. International cooperation against the world drug problem.  New York. 2013; pp: 11-25.
  2. Gelaw Y, Haile-Amlak A. Khat chewing and its socio-demographic correlates among the staff of Jimma University. Ethiop J Health Dev. 2004; 18:179-184.
  3. WHO.  Urgent health challenges for the next decade. https://www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade (accessed 2020 Feb 15).
  4. Abebe, W.  Prevalence and consequences of substance use among high school and college students in Ethiopia: A review of the literature.  African Journal of Drug and Alcohol Studies. 2013; 12:107-118.
  5.     Hagos, EG, Asfeha GG, Berihu BA. Prevalence of substance abuse among regular degree health science students in Sheba University College in Mekelle Town, Tigray, Ethiopia.  J Neurosci Rural Pract. 2016: 7: 200–220.
  6.   Alebachew, W, W, Semahegn A, Ali T et al. Prevalence, associated factors and consequences of substance use among health and medical science students of Haramaya University, eastern Ethiopia, a cross-sectional study. BMC Psychiatry. 2019; 19:343-350.
  7.     Desta, E, Soboka S, Workneh D et al. The Prevalence of Substance Use and Associated Factors Among Medical Interns of Jimma University, South West Ethiopia.  Journal of Substance Abuse and Alcoholism. 2018. https://www.jscimedcentral.com/SubstanceAbuse/substanceabuse-6-1071.pdf (accessed 2020 Feb 20)
  8.     Mossie, TB, GebreMichael, Ayele AD. Magnitude of Psychoactive Substance Abuse among University Students, Adigrat, North Ethiopia: Cross Sectional Study. J Psychiatry. 2015; 18:281-288.
  9.     Birega MG, Addis B, Agmasu M. et al. Descriptive Study on Magnitude of Substance Abuse among Students of Aman Poly Technique College Students, Bench Maji Zone South West Ethiopia.  J Addiction Research and Therapy; 2017; 8:1-5.
  10.   Deressa, W, Azazh, A. Substance use and its predictors among undergraduate medical students of Addis Ababa University in Ethiopia.  BMC Public Health.2011; 11:660-267.  
  11.   Eticha, T, Kidane, F. The prevalence of and factors associated with current smoking among College of Health Sciences students, Mekelle University in northern Ethiopia.  PLoS One. 2014; 9: e111-e121.
  12.   Sensi Seeds. Cannabis: laws, use and history, 2019, https://sensiseeds.com/en/blog/countries/cannabis-in-ethiopia-laws-use-history (accessed 2020 Feb 25)
  13. WHO. Abuse of drugs, alcohol, chemical, substances or psychoactive substances. https://www.who.int/substance_abuse/terminology/abuse/en/ (2020 accessed Feb 22)
  14.   National Institute on Drug Abuse, Commonly Abused Drugs Charts. https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-chart (accessed 2020 Feb 20) 
  15.   Ken C, Winters B, Arria B. Adolescent Brain Development and Drugs. Prev Res. 2011;18: 21–24.
  16.   National Institute on Drug Abuse. Drug, brain, and behaviour, the science of addiction. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction (accessed 2020 Feb 15). 
  17.   Comen E. Victims of the opioid crisis: counties with the worst drug problems in every state. Wall Street august 2, 2019.
  18.   Kebede Y. Cigarette smoking and khat chewing among university instructors in Ethiopia.  East Afr Med J.2002; 79:274-278.
  19.   Gizaw AT, Amdisa D, Kebede Y, Gizaw L et al. Predictors of substance use among Jimma University instructors, Southwest Ethiopia. Substance Abuse Treatment, Prevention, and Policy. 2020; 15:2-12.

Conflict of interest:

The author declares no conflict of interest in relation to the present work.

Corresponding address:

Worku Abebe, PhD

Associate Professor

Department of Oral Biology & Diagnostic Sciences 

CL- 2130, Dental College of Georgia

Augusta University, Augusta, GA 30912-1128, USA

Phone: 706-721-3181

FAX: 706-721-6252

Email: wabebe@augusta.edu  

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