Psychosocial Factors Associated with Initiation and Continuation of Substance Abuse among Preparatory Students in Addis Ababa


 Background

Substance abuse is the use of illicit drugs or the abuse of prescription or over the Counter drugs for the purpose other than those for which they are indicated or in a manner or in quantities other than directed. Substance abuse is an emerging public health problem in Ethiopia, like other African countries.
Methods

School based cross-sectional survey was employed. A total of 326 students were randomly selected from one government and two private schools. The 296 Sample size was calculated using the formula of a single population proportion and calculated using software Epi-info stat calculation by taking 31% proportion from previous study with confidence level of 95% and 5% degree of precision. Non-response rate in this study was estimated to be 10% (30). We use self-administer questionnaire to assess the physiological factors associated with initiation and continuation of substance abuse.
Results

The magnitude and the prevalence of substance abuse were 24.8% and the commonly abused were alcohol (30.8%), kchat (15.4%) and cigarette (11%). Other substances are rarely abused. The study also showed that male students were abused substance [OR, 95% CI: 3.150 (1.451, 8.685)] three times higher than that of females. In addition those who abused substances through peer pressure or [OR, 95% CI: 7.599 (4.571, 16.174)] were eight times more likely to abuse substances in contrast with those who did not. Other psychosocial factors: curiosity, poor family relationship and stress were positively associated with substance abuse.
Conclusion

substance abuse is a threat problem to the public as well as to the preparatory students of Addis Ababa; it is strong positively associated with various variables such as male students, peer pressure, curiosity, poor family relationship and stress of students. Peer pressure was the major precipitating factor for substance abuse followed by curiosity. The most commonly abused substances were alcohol, khat and cigarette. Yet, the magnitude of factors for substance abuse is high. From this, it can be generally said that substance abuse is a pressing issue for preparatory students.


Introduction
Substance abuse can simply be de ned as a pattern of harmful use of any substance for mood-altering purposes. "Substances" can include alcohol and other drugs (illegal or not) as well as some substances that are not drugs at all [1].
Ethiopia is the second largest country in Africa and the population is estimated to be around 85 million where 84.2% resides in the rural part of Ethiopia [2]. Substance abuse is an emerging public health problem in Ethiopia, like other African countries. It affects almost the entire community. Ethiopia is one of the earliest centers of producing alcohol, coffee and kchat [3]. The commonly abused substances are alcohol and kchat followed by cannabis and solvents [4]. Hard drugs like heroin and cocaine are also consumed. Illegal drugs are alcohol, prescription and over the counter medications, inhalants and solvents, and even coffee and cigarettes can all be abused to harmful excess [5].
The prevalence of substance abuse in Ethiopia is estimated to be 20.2% [6]. Youngsters, street children, high school, college and university students and unemployment are high risk groups of substance abuse in Ethiopia [4]. Some data shows substance abuse is a serious problem in Ethiopia but the government has given little attention to substance use and related factors. Psychosocial factors greatly in uence initiation and contribution of substance abuse among high school students and understanding these factor has important implications for intervention and prevention of substance abuse. The government of Ethiopia considers substance abuse as a serious ongoing public health problem it affects almost every community and it has negative health consequences. However, little attention has been given to understanding of the factors related to substance abuse [7].
Psychosocial factors in uence young people towards substance abuse and these factors (peer pressure, curiosity, poor familial relationship and stress) play a pivotal role for initiation and continuation of substance abuse [8]. In our country the prevalence of substance abuse is 20.2% [6].
Students aged 17 to 25 are among the high risk population of substance abusers and substance abuse also common in urban Ethiopia especially, in Addis Ababa. The study is important to examine psychosocial factors for substance abuse and uses as baseline information for intervention. To create awareness among preparatory students in Addis Ababa and to show how the substance abuse is a serious public health problem. The result of this study will bene t to: FMOH: the result from this study can be used to identify psychosocial factors associated with the initiation of substance abuse among preparatory students in Addis Ababa and the federal ministry of health provides support for the treatment and prevention of substance abuse, based on the result.
Stakeholders: NGO which are involved in treatment and prevention of substance abuse and to provide technical support to promote health.
The result of this study important for policy makers to design of the system of substance abuse rehabilitation and treatment centers.
Menelik II preparatory school, Radical Academy and Lazarist Catholic Secondary School: the result of the research will give an opportunity for the community to aware of the devastating health consequences of substance abuse for a person, a family and a community.
Conceptual framework on some psychosocial factors and initiation & continuation to abused substances is illustrated as follows

Materials And Methods
The study was school-based cross-sectional survey, Quantitative method was used to found out the role of psychosocial factors on initiation and continuation of substance abuse using self-administered questionnaire. The 296 Sample size was calculated using the formula of a single population proportion for cross sectional survey and calculated using software Epi-info stat calculation by taking 31% proportion from previous study [7] with con dence level of 95% and 5% degree of precision. Non-response rate in this study was estimated to be 10% (30). The calculated sample size was 296 with non response rate the total sample size was 326 students were recruited in the study. The schools are randomly selected one government preparatory school and two private preparatory schools in Addis Ababa. Strati ed sampling technique will be used to select study subjects from the entire student currently enrolled in three of the schools. A total 326 students from grades 11 and 12 will be strati ed by sex and grade level of the students and subjects will be selected using a simple random sampling (lottery method).
The data were collected by three trained technical assistants. The principal investigator supervised the data collection process along with the school directors.

Data Quality Management
Three data collectors were trained for one day on data collection procedures and supervision techniques. The data collection instrument was pre-tested on 5% of the sample size in Medhanealem preparatory school with similar characteristics of the study unit that was not to be included in the main study before the actual data collection. Some questionnaire contents were modi ed and restructured based on pretested of the sample and I estimated the time for completion of the questionnaire. Close supervision of data collection procedures and data collectors was conducted strictly and frequently. Completeness of the required data was checked on the spot by the principal investigator. The questionnaire was checked for completeness and consistency before data entry by the principal investigator and the completed questionnaire was coded.

Data analysis
Obtained data were checked for accuracy and then were entered and analyzed by using SPSS Version 20.0 for statistical analysis. The prevalence of substance abuse was analyzed by descriptive statistics using frequency and percentages and Cross tabulation show the association between independent variable and dependent variable and to compare drug users with non-drug users. Bivariate statistical method was used to investigate the association between psychosocial factors (peer pressure, curiosity, family relationship and stress) and initiation and continuation of substance abuse. Multiple logistic regression models were used for substance abuse and its associated factors and odds ratio and 95% con dence intervals were reported. Signi cant differences is de ned as those with (P < 0.05).

CAGE-AID: CAGE Questions Adapted to Include Drug Use
Scoring Item responses on the CAGE questions are scored 0 for "no" and 1 for "yes" answers. A total score of two or greater positive (yes) answers of the above four questions is considered as ful ll the criteria of substances abused.  Magnitude and number of ever used substances students in three schools The percentages of ever use of any substance among students were 73.4%, 70%, and 42.8% in Radical, Lazarist and Menelik respectively. Among the ever users of substances, 35% Lazarist 29.4% Radical and 20.8% Menelik students used only one drug i.e. alcohol. Whereas 10%, 7.6% and 2.9% were used two substances from Lazarist, Menelik and radical preparatory schools respectively. And the frequency of ever use of three substances among students were 11.8% in Radical, 5% in Menelik and 3.8% in Lazarist. There were also poly drug users in Menelik 3.4% and in Radical 2.9% but no in Lazarist see (Fig. 3). of Menelik students were currently smoke among ever smokers. Cannabis, heroin, hashish and sleeping pills were the least current used substances. The frequency distribution of current use among ever used "drugs" by students from the different preparatory schools is displayed in Table 3.  The prominent reasons for starting to use substances among students from the three schools was were due to peer pressure 42.8%, curiosity 29.2%, poor family relationship 17.9% and the least was stress 10.1% Cross tabulation of Psychosocial factors for initiation and continuation of substance abuse among students in Radical, Lazarist and Menelik preparatory school Table 5 shows that students whose friends were substance user had more likely use substance in their life time (72.1%). Respondents who accept drug and alcohol invitation from peers had a more likelihood reporting drug use in their life. 90.5% and 66.7% of respondents were answer agree and strongly agree respectively. And students who have excellent (54.6%) and good (41%) network and relationship with peers had much higher prevalence substance use than those who had poor (31.2%) network and relationship.
Out of ever users 65.7% and 45.5% students respond agree and strongly agree respectively, and they had curious nature and try out everything this leads to use substance. Participants who had strong desire to taste substances were more likely to use substances than those who do not desire to taste and the prevalence was 83.9% agree 81.8% strongly agree. And seeking substance opportunity had also strong association with initiation and continuation of substance use among students.
Students whose parents were live together had a lowest likelihood of reporting drug use in lifetime (45.1%). The prevalence of drug abuse among respondents whose parents were separated and divorced was 48.3% & 50% respectively. Those students whose mother and or father dead had higher prevalence of substance use 64.9%. In short, those who had poor or bad relationship with father and mother would have a higher prevalence of substance use in their life time than those who had good relationship with their parents.
Among ever user of substance 52.4% of students respond feel of stress and likely to use substance than those who had no feeling of stress 39.8%. Students engaged in stressful event more likely to use substance use. 75.8% and 72.2% of students answered strongly agree and agree respectively, that being engaged in stressful event leads to initiation and continuation of substance use.
The associations of psychosocial factors or variables related to initiation and continuation of substance use were signi cantly present with chi-square tests as shown in Table 5.  Table 6).

Discussion
The ndings of this study indicate that the prevalence of 24.8% of preparatory students in Addis Ababa were abuse substances. This high prevalence was remained slightly higher as compared with 20.2% prevalence of substance abused obtained from national ndings [6]. But it is much lower than a study conducted by students from public Midwestern University (48.1%) [9].
The investigation of this study showed that the commonly abused substances were alcohol 30.8%, kchat 15.4%, and 11% cigarette. 3.5% of students abuse Cannabis, heroin, and hashish and 2.1% of respondents were abuse sleeping pills. As compared with the prevalence, reports from Kenyan secondary school showed that alcohol 42.9% khat 20.8% cigarette 19.8% cannabis 14.3% and sleeping pills 3.8% were the most commonly abused substances and this study also support and indicated that alcohol was the most commonly abused substance than others, which was similar to this nding [10].
The prevalence of alcohol, kchat and cigarette abuse was higher than other substances due to cultural, social and legal acceptability. Among the social substance, alcohol does not affect health when moderately consumed. It is also widely available, easily accessible (especially home remedies), high exposure to alcohol advertising and has market coverage. These are the reasons why alcohol is the most commonly abused substance, unlike other substances.
According to this study, Male students were more likely to abuse substances than female students. This is also similar to the study conducted in Mekelle university students [11]. Students who started to use substances through the in uence of peer pressure were positively associated with abuse of substances.
This is similar to a study conducted in Kenyan secondary school [10] and Mekelle University students; peer pressure into initiation factors for substance use was positively associated with substance abuse [11]. One of the psychosocial factors which were strongly associated with substance abuse is the curiosity of the students to explore new experiences.
Various studies highlight that the role of curiosity also has a strong positive association with the initiation and continuation of substance abuse among Hungarian secondary high school students [12]. Similarly, respondents in this who started to use substances due to poor family relationships were positively associated with substance abuse. This is in agreement with studies conducted and investigated by Paul [13] more importantly; young people with a poor relationship with their parents are likely to abuse substances than those who have healthy relationships [14]. Stress found to have a strong association with substance abuse among schools where this study was conducted. The ndings of this study reveal the prevalence of ever users of substances among students was found to be 73.4%, 70% and 42.8% in Radical, Lazarist and Menelik respectively. This is lower than ndings from Mekelle University students (82.7%) and students in Nigerian medical university (78%) (Igwe, 2009). And higher than Nigerian secondary school students, 63.3% [15].
The prevalence of substances among ever users of students were, 35% Lazarist 29.4% Radical and 20.8% Menelik had taken only one drug that is alcohol, whereas 10%, 7.6%, and 2.9% were used two substances from Lazarist, Menelik, and radical preparatory schools respectively in their lifetime. And the percentage of ever use of three substances among students was 11.8% in Radical, 5% in Menelik and 3.8% in Lazarist. There were also poly-drug users in Menelik 3.4% and Radical 2.9% but not in Lazarist. In contrast with ndings reported from Mekelle University Among the ever users of substances, were 58.1% of students consumed only one drug whereas 42% were poly-drug users.
Substance abuse was signi cantly high among students of the private preparatory school compared to that of government school students in Addis Ababa. The difference in the educational program in Addis Ababa could be contributing factors to this varying rate of substance consumption.
Other ndings in this survey were the time of initiation for substance use was reported to be 57% of the ever users began at secondary school. This is different from reports taken from students of Debre Markos Poly Technique College 36% during their secondary school life. The reason for this should be the different participants' study area, Addis Ababa and that what has been reported from the Debre Markos.
The survey further showed that 42.8% of the study participants were introduced and initiated to use substances by peers or friends. 29.2%, 17.9%, and 10.1% were by curiosity, poor family relationship and stress respectively. As I have already indicated that peer pressure was the prominent psychosocial factor reason for the initiation and continuation of substance abuse among students in private and government preparatory schools. These factors occur sequentially but independently of each other. This result is much lower than 75.1% of students introduced to use substances by peers in Nigeria secondary school. Similar to this, a study conducted in Kenya secondary school stated that peer pressure is the prominent reason for substance abuse.
The present study revealed that students whose friends were substance users or abusers had more likely to use a substance in their life (72.1%). Similarly, studies conducted by Pedersen & Skrondal found that students who have friends' use of substances had more likely to use substances than those who did not [16].
Participants who had a strong desire (curiosity) to try substances were more likely to use substances than those who do not and 83.9% of participants were answered agree and 81.8% strongly agreed. In agreement with other ndings, 75.8% of the respondents said they rst tried illegal substances were due to curiosity [17]. The difference is due to the method difference between the present study and the referred one.
Respondents whose mother and or father dead, divorced and separated had a higher prevalence of substance use 64.9%, 50%, and 48.3% respectively than those who did not. Similar reports also found by Yip et al [13] and support that students those who had very poor parent's marital relationship, bad relationship with parents, would have a higher prevalence of drug use.
Other ndings from this study also that symptoms or feelings of stress likely to use substances than those who had no feeling of stress. This result also supported by Kaplow et al and he noted that the number of symptoms related to stress at baseline predicted who would start/initiate and continue to use the substance [18].
In general, the difference showed in the above discussion may be due to the population size difference in the study, and the differences in school policies and advertisement of publicity. The difference in the educational system in private and government schools between countries could also be contributing factors for this varying rate of use and abuse of substances. Institutional property variables of schools, physical and behavioral property variables of schools, including the type of residence, institution size, location, and schools community property variables, including availability and outlet density could also be reasons for the variations.

Conclusion
This study aimed at assessing the magnitude of substance abuse and associated psychosocial factors among preparatory students. It identi es substance abuse is a threat problem to the public as well as to the preparatory students of Addis Ababa. It is strongly positively associated with various variables such as male students, peer pressure, curiosity, poor family relationship and stress of students. Peer pressure was the major precipitating factor for substance abuse followed by curiosity. The most commonly abused substances were alcohol, khat, and cigarette. Yet, the magnitude of factors for substance abuse is high. From this, it can be generally said that substance abuse is a pressing issue for preparatory students.

Consent for publication
Written informed consent of each study participant was obtained before data collection. con dentiality was strictly maintained during the process of assessment of psychosocial factors associated with initiation and continuation of substance abuse among preparatory students. as well as anonymity was kept during data processing and report writing. Finally ndings of the study communicated to the preparatory school management body for corrective measures still keeping anonymity.

Availability of data and materials
All data generated and/or analyzed during the study are with the author and will be available on request at any given notice.

Competing interests
The authors declare that they have no competing interests   Reason for initiation and continuation of substance use