Knowledge of health effects and determinants of psychoactive substance use among secondary school students in Sokoto Metropolis, Nigeria

Introduction psychoactive substance use (PSU) is a patterned use of a drug in which the user consumes the substance in amounts or methods which are harmful to themselves or others. Psychoactive substance use takes a considerable toll on financial status, academic achievement and health status of addicts. In Nigeria, PSU is on the increase, one of the most disturbing health-related problems and a leading cause of premature death among school aged population worldwide. We therefore, determined the knowledge of health effects and determinants of psychoactive substance use among secondary school students in Sokoto Metropolis, Nigeria. Methods we conducted a cross-sectional study among 430 secondary school students that were selected using multistage sampling in Sokoto, Northwestern, Nigeria from April to May 2019. We collected data using a semi-structured, interviewer-administered questionnaire. We calculated proportions and adjusted odds ratios (OR) with 95% confidence intervals (CI) in a binary logistic regression model. Results knowledge of health effects of PSU was good in 38.1% of the respondents with a mean score of 19.6 ± 10.0. The overall prevalence of PSU was high among current users (16.3%), male participants (78.6%) and those aged 17-years or more (68.6%). Independent predictors of current use of psychoactive substances were poor knowledge of health effects (aOR: 4.1, 95% CI: 1.7-10.0) and father´s use of psychoactive substances (aOR: 10.3, 95% CI= 1.9-57.1). Conclusion knowledge of health effects of psychoactive substances was generally poor among the participants with an associated high prevalence among current users. Poor knowledge of its health effects determines the use of psychoactive substances. We conducted awareness campaigns and health talk on health effects of PSU to secondary school students in the State. The Federal Ministry of Education should ensure that PSU-related topics are incorporated in the secondary school curriculum.


Introduction
Psychoactive substance use constitutes a major public health and social problem worldwide, with alcohol, tobacco and marijuana being the most commonly used [1]. These drugs take a huge toll not just financially, but in lost potential in academic achievement, poor health and untimely death [2]. Globally, over 29 million people suffer from drug use disorders, and of those, 12 million are people who inject drugs (PWID) of whom 14.0% are living with HIV [3]. In developing countries, recent trends indicate that the use of psychoactive substances (PASs) has dramatically increased [4]. Studies have shown a rise in consumption, as well as early initiation, increasing female involvement, and a trend towards multiple substance use among adolescents in Nigeria [5]. Epidemiological data from school surveys in Nigeria have shown that substance abuse is common with a rising prevalence and a decreasing age of onset. It is also one of the most disturbing health-related problems among youths [5]. Most often the adolescents and young individuals start by experimenting with the so-called "gateways drugs" such as tobacco, alcohol and later progress to more dangerous ones such as marijuana and cocaine [5,6].
Police reports revealed that cannabis, and recently codeine and shisha are available on the Nigerian streets of urban areas [7]. Although to a lesser extent cocaine and psychostimulants are also known to be abused in this country [7]. In Birnin Kebbi North-Western Nigeria, lifetime prevalence and current prevalence of tobacco smoking were 32.2% and 20.8% respectively [8]. Literature suggests that peer influence, family factors and personal background play an important role in the development of youth substance use behavior [9]. It is not rare for Nigerian secondary school students to consume alcoholic drinks; this consumption could be due to their curiosity as adolescents, an irresistible urge, emotional disturbances such as anxiety, the subculture, and the influence of advertisements [10]. Young people such as secondary school students particularly those who consume psychoactive substance are more prone to engaging in high-risk behavior, which include unprotected sex, early sexual debut or sex with multiple partners, in addition to strong relation to perceived academic achievements [11]. Abuse of drugs not only holds back the economy but is also a blow to the country as its youths become less productive [7]. Adolescents´ knowledge of health effects of psychoactive substance use is very fundamental when undertaking research aimed at psychoactive substance cessation interventions. However, the extent of consumption among secondary school students and their understanding of its effects on human health is poorly documented in many Nigerian States including Sokoto [10]. This study was therefore conducted to assess the knowledge of health effects and determinants of psychoactive substance use among secondary school students in Sokoto Metropolis, Nigeria. Study design and population: a cross-sectional study was conducted among secondary school students from April to May 2019. Only the students in public and private secondary schools registered by the government (as indicated in the list obtained from the state ministry of basic education board) were considered eligible. Those who were not regular students (students on excursion, external Senior Secondary Certificate of Education (SSCE) candidates) were excluded.

Sample size estimation and sampling technique:
the sample size was estimated using the statistical formula for calculating the sample size for descriptive studies [3].
With a 50.7% expected prevalence (p) of psych oactive substance use from a previous study, [6] a precision level (d) of 5%, and an anticipated 90% response rate. A total of 430 students were ultimately enrolled into the study. The eligible participants were selected using a multi-stage sampling technique. At the first stage, 2 of 4 metropolitan LGAs -Sokoto South and Wamakkowere randomly selected by balloting. At the second stage, the schools were stratified into public and private, line listing of all the public and private schools in the selected LGAs was done, and 12 (8 public and 4 private) of 27 (19 public and 8 private) schools were randomly selected by balloting using equal allocation of 6 (4 public and 2 private) schools from Wamakko and Sokoto South LGAs respectively. At the third stage, students were stratified into junior and senior classes, line list of all students was obtained from the respective schools and proportionately allocated. However, systematic sampling technique (with replacement) was used to recruit study participants from the respective schools.
Data collection and analysis: a pretested structured interviewer-administered questionnaire was used to collect data on the respondents´ sociodemographic characteristics, knowledge of health effects of psychoactive substance use, prevalence and pattern of psychoactive substance use. The questions were adapted from different validated questionnaires [2,4,12]. The face and content validity were carried out by the principal researcher´s supervisors who are expert in the field, whereas the test-retest reliability was conducted to establish the reliability of the instrument where a reliability coefficient of 0.812 was achieved. The questionnaire was pretested on 43 secondary school students in Sokoto North LGA, and appropriate corrections were made based on the deficiencies detected in the instrument during the pretesting. Four unemployed graduates and two undergraduates of tertiary institutions in Sokoto State were trained and assisted the researcher in data collection. The training focused on the conduct of research including research ethics, objectives of the study, selection of study participants and use of the survey instrument. Knowledge section consists of 39 questions. Correct response on knowledge of health effects of psychoactive substances was scored one mark, while incorrect response was scored zero and the aggregate scores for each respondent were reported in proportions. Knowledge scores ≥ 23.4 (≥ 60%) and < 23.4 (< 60%) were graded as good and poor knowledge respectively [13]. Descriptive statistics analysis such as mean and standard deviation were done for continuous variables whereas, categorical data were presented in frequencies and proportions. Chi-square and Fisher´s exact test were also performed to determine the association between independent and dependent variables whereas binary logistic regression model was used to identify factors that predicted psychoactive substance use among users. IBM Statistical Package for the Social Sciences (SPSS) version 23 software was used for the analysis. All levels of significance were set at p < 0.05.
Ethical consideration: institutional ethical clearance was obtained from the Ethical Committee of Sokoto State Ministry of Health, Sokoto, Nigeria (SMH/1580/V.IV). Permission to conduct the study was obtained from the Honorable Commissioner, Ministry of Education, Sokoto State, Nigeria. In addition, a written assent was obtained from students below the age of 18 years and consent was also sought from the principal/guardian or parents as the case may be. Participants were assured of strict confidentiality of their responses and informed that their participation is voluntary and would incur no loss if they refuse to participate in the study.

Results
A total of 430 participants were recruited to participate in the study and all completed the interview, giving a response rate of 100%.  (Table 3). Most [44 (62.9%)] of those that currently used psychoactive substance, used it at least once every 6 to 19 days (Figure 1). Secondary school students who had poor knowledge of psychoactive substance were more likely to be current users compared to those with good knowledge (aOR: 4.1; 95% CI= 1.7-10.0). Also, those whose fathers used one or more psychoactive substance were more likely to be current users compared to those whose fathers did not use any substance (aOR: 10.3; 95% CI= 1.9-57.1) ( Table 4).

Discussion
This study assessed knowledge of health effects and determinants of psychoactive substance use among secondary school students in Sokoto metropolis, Nigeria. More respondents in this study were males. The sex distribution in this study is consistent with those obtained in several studies in Nigeria and abroad [7,8,14,15]. The preponderance of males in Nigerian secondary schools could be explained by the societal culture and attitude, especially in the northern part of the country that seems to favour the male child [3]. However, female child education has been on the rise not only in southern but also in the northern part of Nigeria [16]. This study demonstrates the knowledge of health effects of psychoactive substance to be good in at least a third of the respondents (38.1%) with a mean knowledge score of 19.6 ± 10.0. This finding is much lower compared to what was reported in Owerri, Southeastern Nigeria, Tanzania and India where they reported good knowledge of health effects of psychoactive substance use among students as 63.1%, 98.5% and 84.6% respectively [7,17,18]. Finding in this study could be as a result of scores obtained by the respondents in different sub-section questions that addressed knowledge of health effects of psychoactive substance use. For example, on knowledge of physical health effect, slightly above half of the respondents knew accident and hypertensive heart disease as physical health effects of psychoactive substance use as against 70.7% and 58.5% reported by Gotsang et al. in Botswana for traffic accident and heart diseases respectively [19]. Regarding knowledge of psychological health effects only about two-thirds of the respondents knew mental illness as psychological health effect as against 74.9% reported in Botswana [19].
The current PAS use prevalence of 16.3% was high in this study; this highlights the importance that any drug abuse preventive measures, formal policies on drug abuse need to be implemented much earlier in the student´s academic lives to achieve desired objectives. The finding is slightly lower than 20.8% reported by Gana  . These differences could be as a result accessibility of the type of substance studied, or it could be as a result of disparities in methodologies and socio-cultural characteristics of the respondents. In this study, the distribution of current users of psychoactive substance was disproportionate according to gender, where more than two-thirds were males. However, these findings were comparable to the findings of studies by other authors, where similar results were noted [1,14]. This may be because males are more likely to be adventurous than their female counterparts and they are more likely to be experimenting during their adolescent years. Females, on the other hand, enjoy more supervision of parents/guardian because of the fear that their engagement in social activities could predispose them to being wayward [22].
The most frequently used substance among male respondents were tobacco and shisha, while the least used being cocaine and diazepam. Whereas, among female current users, the most frequently used substances were shisha and energy drink, while the least consumed being Kolanut and Rohypnol; this contrasts with the finding in a study by Mosibo et al. who reported alcohol use 47.1% as the most frequent and codeine 5.9% and heroine 5.9% as the least frequent among males [7]. This indiscriminate use of most frequently used substance may partly result from easy access and availability. Over the counter (OTC) purchases being a common phenomenon in Nigeria as compared to least used psychoactive substance that are mostly controlled drugs. Some of the reasons given by our respondents for psychoactive substance use were to reduce stress, be acceptable to friends, increase pleasure of life, enhance work performance, admiration by others and become more influential among peers. These were similar to findings reported in Owerri South-Eastern Nigeria, Botswana and India for initiation of substance use which included peer influence, to relieve stress, to increase pleasure of life and to be like their friends/relatives/role model [17][18][19].
A majority of the users in this study used a substance at least once every 6 to 19 days in a month. Whereas, less than a quarter (17.1%) were using them between 1-5 days in a month. Similar though much lower frequency of use was reported by Gana et al. in Birnin Kebbi where almost a quarter (23.6%) of smokers smoked cigarettes for more than five days during the previous month; [8] this highlights the rate at which adolescents are beginning to imbibe psychoactive substance use as a way of life. Factors found to predict current use of psychoactive substances in this study were respondent´s knowledge of health effects and father´s use of psychoactive substances. Shehu et al. in Zaria reported family background as a factor that influenced marijuana smoking. Contrary to the finding in this study, he reported peer pressure and attendance of social functions as factors that also influence marijuana smoking [20]. The strengths of the study lie in its ability to determine that the knowledge of health effect of psychoactive substance use was barely good in only about a third of the respondents. It also provides evidence-based information on the point prevalence as well as the pattern of psychoactive substance use among secondary school students that could be used in recommending to the ministry of education how to address this menace. A major weakness in this study is the inability to explore some of the emerging psychoactive substances mentioned by the respondents as others, for example, Chaku Basir. These substances could have been known in greater details if we had included qualitative techniques in the study design. Also, due to the sensitive nature of issues associated with the study, some of the respondents refused to open up, we minimised this by educating the study participants on the importance of the study in addition to informing them that the information given cannot be traced back to them and reassurances about confidentiality of information given by them.

Conclusion
Knowledge of health effects of psychoactive substances was generally poor among secondary school students in Sokoto State. The prevalence of psychoactive substance use was high among them. The poor knowledge of health effects and having a father using psychoactive substances were predictors of psychoactive substance use among the study participants. Sokoto State ministry of basic and secondary education in collaboration with State ministry of health should provide periodic awareness campaigns on health effects of psychoactive substance use to all secondary school students in the State. The federal ministry of education should consider inclusion of psychoactive substance related topics in secondary school curriculum.  Table 1: socio-demographic characteristics and family background of respondents Table 2: respondents' knowledge of health effects of psychoactive substance use Table 3: pattern of psychoactive substance use by sex among current users