Khat chewing practice and associated factors among medical students in university of Gondar, Ethiopia, 2019: a cross-sectional study


 Background: Globally, khat chewing practice becoming an alarming and common among the youth generation especially in higher educational institutions. It may also leads to frequent misbehavior, poor academic performance and memory impairment among students. This study aimed to determine the prevalence of khat chewing and associated factors among medical students in University of Gondar, Northwest Ethiopia, 2019.Method: An institution-based cross-sectional study was employed on 422 medical students. Data were collected using a self-administered questionnaire and analyzed using SPSS 20 software. Stratified followed by random sampling was employed to select the samples. Multivariable logistic regression model was fitted to identify the predictors. P ≤ 0.05 was used to select statistically significant factors.Result: The current prevalence of khat chewing among medical students was 21.5%. The odds of khat chewing was higher among males [AOR=3.353; 95%CI (1.460-7.701)], Muslims [AOR=6.390; 95%CI (1.903-21.460)], fifth and six year students [AOR= 3.391; 95%CI (1.354-8.488)], smokers [AOR=5.081; 95%CI (1.898-13.601)], alcohol users [AOR=4.872; 95%CI (2.094-11.332)], students who had khat chewer close friends [AOR=30.645; 95%CI (12.261-76.589)].Conclusion: Since a significant proportion of students chew khat, continuous awareness creation on the impact of khat chewing and counseling services are recommended.


Introduction
Khat (Catha edulis) is an herbal product consisting of the leaves and shoots of the Catha edulis Forsk shrub, a member (genera) of the evergreen celastracae family that is cultivated in most parts of the world, particularly in Eastern Africa and Arabia [1,2]. It is also widely cultivated in Ethiopia [3]. Khat is chewed for its stimulatory effect due to the presence of more than 40 psychoactive substances contained in fresh leaves of the herb [4]. The dominant stimulator ingredients includes cathinone, cathine, and norephedrine [5]. These psychoactive substances stimulate chewers through the autonomic sympathetic nervous system, commonly called the 'fight or flight' response [6].
Students consumed khat to remain alert and wakeful at night, especially during examination periods.
The detrimental personal and social effects of khat chewing are well understood. In addition to economic and social impacts, chronic use of khat is associated with increased blood pressure/hypertension [21,22], development of gastrointestinal tract problems [22], cytotoxic effects on liver and kidneys [22][23][24][25], and keratotic lesions at the site of chewing [21], malnutrition, psychotic reactions after chronic use, depressive reactions, myocardial infraction and cardiovascular disorders [22,26,27], male sexual dysfunction [26], stroke and death [28]. Despite its health, social and economic impact; khat chewing becomes common practice among students and youths in Ethiopia.
Khat chewing practices among university students, particularly those of medical students who spend a long time studying in universities, must be further studied. Therefore, the aim of this study was to assess the prevalence and associated factors of khat chewing among medical students enrolled at the University of Gondar in northwest Ethiopia.

Study design, area and period
In stitutional-based cross-sectional study design was conducted at College of Medicine and Health Sciences (CMHS), University of Gondar from March 1 to June 26, 2019. There were a total of 1708 4 medicine students at CMHS, University of Gondar, which was chosen for this study because medical students study for long periods of time and generally have more exposure to stress.

Source and study population
All medical students in the CMHS were the source population, and the students who were present during the data collection period were the study population.

Inclusion and exclusion criteria
Medical students who were severely ill during the data collection period and students who had hearing and speaking difficulty were excluded.

Sample size and sampling procedure
A single population formula was used to estimate the sample size by considering the prevalence of khat chewing was 50%, confidence level of 95%, 5% margin of error and with the assumption of 10% non-response rate. Then, the final sample size became 422. After taking the list of medical students from the registrar office of the University of Gondar, stratified proportional sampling followed by a computer-generated simple random sampling technique was used to select the study participants for this study. The stratification was formed from 1 st -6 th year medicine students.

Data collection procedure
Data were collected by three environmental health professionals using a pre-tested self-administered structured questionnaire. The training was also given for data collectors before data collection period.

Operational definition
Khat chewer: the one who chew khat for at least one time in his life [29].
Lifetime prevalence of khat: the proportion of students who had ever use khat in their lifetime [13].
Current prevalence of khat: the proportion of students who were chewing within 30 days preceding the study [13]).

Data quality control
The questionnaire was pre-tested and training was also given for data collectors. Data were checked for completeness, coded and entered appropriately prior to the analysis.

Data processing and analysis
Data were entered and cleared using EPI-INFO version 7.0.0 statistical package and export into SPSS software version 20 for further analysis. Bivariable logistic regression analysis was performed to find the association of each independent variable with khat chewing. All variables with a P-value of 0.25 at bivariable logistic regression analysis were entered into the multivariable logistic regression model. Pvalue ≤ 0.05 was considered statistically significant. Adjusted odds ratio (AOR) and its 95% confidence interval (CI) were calculated for potential associated factors included in the final model.

Socio-demographic characteristics of respondents
Four hundred and twenty two subjects were included in the study and the overall response rate was 409 (96.95%). About half (50.4%) of the respondents were males. The majority of students were within the age of 20-24 years old (72.1%). Most of them were orthodox 264 (64.5%) and followed by Muslims 55 (13.4%) (table.1).

Discussions
The finding of the present study revealed a significant proportion of medical students found to be khat chewer, which implies the university and other responsible bodies need to have a series of attention in controlling of the increasing khat chewing practice. Sex, Religion, year of study, smoking habit, drinking alcohol habit and having khat chewer close friends were significantly associated with khat chewing practice among medical students. In this study, the lifetime and current prevalence of khat chewing among medical students of university of Gondar found to be 23.7% and 21.5 respectively. This finding was consistent with other studies conducted among preparatory school 11 students in Bale Zone 23.6% [14], high school students in Harare town 24.2% [17] and in Dire Dawa 27.7% [11]. This consistency may be due to cultural and age group similarity between the study populations. However, the result of the study was lower compared to the study conducted among college students in Gondar town 42% [30], among Adama university students 40.0% [16] and among Axum university students 28.7% [13]. The reason might be the difference in the surrounding in the universities and most students in our study area are on campus where there is high control as compared to the above mentioned areas. The result of the study was also higher than other study conducted among medical students of Addis Ababa University 7% [19], among students of Debre-Markos Poly Technique College 7.8% [18]. The reason might be the accessibility and availability of khat chewing to the university and acceptance of the student to the habit.
This study showed that the habit of khat chewing was 3.353 times higher in males than females, which is in line with research findings reported for Jimma university students [15], for college students in Northwest Ethiopia [17] and for college students in Saudi Arabia [31]. This might be due to the common social and cultural restrictions on females khat chewing practice compared to males in Ethiopia.
Muslim students were 6.390 [AOR 95% CI= (1.903-21.460)] times more likely to chew khat than other religious followers. This is also consistent with the finding of other studies in Ethiopia and abroad [13][14][15]19]. This association might be due to the fact that khat hewing practice has traditionally been confined to Muslim populations, and also it might be due to the religious dogma.
This study showed that fifth and sixth year students are 3.391 times more likely to chew khat. The reason might be their long waiting time in the university may cause depression and also faces more peer pressure/influence and they focus more on social interactions than academic issues than other year students.
Students who have chat chewer friends were 30.645 times more likely to chew khat. This finding is also in line with other studies [13,17,19]. This is because respondents who had khat chewing friends tend to imitate and exercise what they see from their peers due to peer-pressure and need of socialization.
Students who smoked cigarette are 5.081 times more likely to chew khat. This finding is also in line with other studies [13,15,19]. Students who drank alcohol are 4.872 times more likely to chew khat.
This indicates that there is a clustering of a substance use behaviors among students of khat chewing habit.

Conclusion
Significant proportion students were khat chewers. Sex, Religion, year of study, smoking habit, alcohol drinking and having close friend who chews khat were important predictors of khat chewing practice. The university is recommended to create awareness for students, strictly ban the use of khat and provide counseling programs for students to help in coping with the problem.

Limitations Of The Study
Since it is a descriptive cross sectional study, doesn't show cause and effect relationship. Since the issue is sensitive, there may be social desirability bias. Findings from this study may not be generalized to the whole young people, because the study involved only University students.
Abbreviations AOR: adjusted odds ratio; CI: confidence interval; CMHS: college of medicine and health science

Acknowledgments
We would like to thank University of Gondar for its support to conduct this research. We would also like to thank our study participants and data collectors for their willingness and cooperation in collecting all necessary data for the success of this work.

Authors' contributions
LY: prepare the tools, collect, analyze and interpret the data. WW: Advise throughout the process. TA: Advise throughout the process and prepare the manuscript. JA: reviewed the manuscript. All authors read and approved the final manuscript.

Funding
There is no specific funding for this study.

Availability of data and materials
All data underlying the findings are fully available without restriction. All relevant data are within the 13 manuscript.

Ethics approval and consent to participate
Ethical approval was obtained from the Institutional Review Board of University of Gondar. Written informed consent was also taken from the study participants. Confidentiality of information was also kept properly.

Consent for publication
Not applicable.