University Students’ intention to quit substace abuse in Ethiopian: Application of Theory of Planned Behavior

this study aims to assess substace Ethiopian:Application of Theory of Planned Behavior (TPB) Methods Institution based cross-sectional study was conducted using self-administered questioners. A stratified sampling technique was used to select the study participants. Descriptive statistics were computed and a multivariate logistic regression model was fitted. A p-value of less than 0.05 was used to declare statistical significance. Result From a total of 392 respondents, 175 (44.6%) were fulfilled the criteria of psychoactive substance abuse (CAGE ≥ 2). Socio-demographic variables such as male respondents (Adjusted Odds Ratio (AOR) =2.34, 95% confidence interval, CI [1.22, 4.51]; P=0.000), Respondents among age category of 25-29 years (Adjusted Odds Ratio(AOR)=21.93, 95% confidence interval CI[16.19; 33.11]; P=0.000) and students with five and above years of study (Adjusted Odds Ratio (AOR)=5.71, 95% confidence interval, CI[2.41-13.52]; P=0.000) had significant association with the psychoactive substance abuse. Theory of Planned Behavior constructs such as positive attitude (Adjusted Odds Ratio[AOR]=1.81,95% confidence interval, CI[1.11,2.96]; P =0.018),supportive Subjective Norm (Adjusted Odds Ratio[AOR]=2.05, 95% confidence interval, CI[1.26,3.47]; P =0.004) and positive Perceived Behavioral Control (Adjusted Odds Ratio [AOR]=6.16, 95% confidence interval, CI[3.75,10.14]; P =0.000) had significant association with quitting psychoactive substance abuse. study that predicted a attitude, behavioral

mood or thinking processes [1]. Many countries including Ethiopia recognize that substance abuse by young people is a serious health and social problem. Students are among the high-risk population of substance abusers [2]. Khat, also called Catha edulis, an amphetamine-like substance which is a bush native to East Africa and Arabian Peninsula for more than a thousand years is widely used in Ethiopia, Yemen, Somalia, and Kenya; it is consumed by chewing the leaves of the plant [3].
The death from tobacco alone is projected to be 8.4 million by 2020 [4]. A study done at Trakya University, Turkey, students revealed that 30%, 29.9%, and 3.1% of the participants used alcohol, tobacco, and marijuana, respectively [5]. Another study was done at the University of Abuja, Nigeria, reported that 57.3%, 35.7%, 24.0%, 1.7% of undergraduate students used stimulants, alcohol, tobacco, and opium/heroin, respectively [6]. Some study reports showed that that factors like students with a high amount of pocket money, being male, whose parents experienced more conflict in their relationship, and who belong to families with higher education and income level [5,6] were leading the students to psychoactive substance abuse. However, a study reported that as a consequence of abusing psychoactive substance university students developed study difficulty, psychiatric morbidity, and brain flag syndrome [6].
One review study reported that between 0.3 to 64.7% of the population of Ethiopia consumed khat.
Besides, the report showed that 3% of the population of Ethiopia had hazardous drinking. Both students and staff of higher institutions were at high risk of substance abuse. Thirty-one percent of students at the higher institute of Ethiopia were current alcohol users followed by 26.3% and 23.3% current cigarette smokers and khat chewers respectively [7]. Khat, alcohol, and tobacco are legal to use in Ethiopia even by the youths, except alcohol. Khat is a legal drug like cigarettes and alcohol in Ethiopia, openly sold at markets and chewed in streets.
The Theory of Planned Behavior (TPB) assumes that the best predictor of behavior is a behavioral intention which in turn determined by attitude toward the behavior, social normative perceptions regarding it and perceived behavioral control of performing the behavior. It constitutes a proficient framework for predicting behaviors and intentions. The TPB has been used successfully to predict and explain a wide range of health behaviors and intentions including health services utilization [8].
Studies have applied theoretical models to identify factors associated with the utilization of Voluntary Counseling and Testing services, while others have tested the applicability of the TPB to predict the intention of various sexual behaviors such as the intention to use a condom and intended use of contraception in Africa [9,10,11]. Studies conducted in Ethiopia [12,13] and Uganda [14] showed that subjective norms were more important predictors than attitude and Perceived Behavioral Control (PBC). Finally, another Ethiopian study showed that the strongest predictor of reporting intention was PBC [15].
We believe that the applicability of socio-cognitive models to the African context in general and Ethiopian context, in particular, should be systematically addressed; considering the need to develop of theory-guided studies for explicit interventions programs for psychoactive substance abuse. To this end; there was no study conducted on this issue to test the applicability of TPB in predicting the intention to quit substance abuse in the country to the best of our knowledge. Therefore; this study aims to focus on intention to quit psychoactive substance abuse in the university student's application of the theory of planned behavior among University students in Ethiopia (Fig-1).

Methods And Materials Study Setting and Period
The study was conducted from February to March 2018 among Arbaminch University, Arbaminch town Southern Ethiopia. Arbaminch town is located at 505 km from Addis Ababa, the capital city of Ethiopia. Arbaminch University has five campuses: Nech sar campus, Abaya campus, Chamo campus, kulfo campus, and main campus. Within all campuses, there are thirty-nine departments and 17,132 regular undergraduate students. There is no treatment and rehabilitation center and peer group counseling related to substance use within the whole campus.

Study design
An institution-based descriptive cross-sectional study design was used.

Participants and Sampling
From available departments, the study randomly selected 20 departments using the lottery method.
To determine the sample size, single population proportion formula was used with the necessary assumptions of prevalence (p) 50% psychoactive substance abuse among undergraduate regular Arbaminch University Students with a 95% confidence level, 5% margin of error.
Considering the multistage nature of the sampling technique, a design effect of 2 was used to multiply the sample size as 384*2 = 768. Since the number of regular undergraduate students is 8966 (< 10,000) correction formula was employed. By considering a 10% non-response rate, 845were taken as final study sample size.
A stratified simple random sampling technique was used to select the 845 study subjects from the entire regular undergraduate students currently learning in Arbaminch University. In this case, the students from the selected 20 departments were stratified by batch and sex. Finally, respondents were selected using simple random sampling.

Data quality control
An elicitation study was done on 15 samples of University students to explore the underlying behavioral beliefs, normative beliefs and control beliefs as per the recommendation by the creator of TPB. This was done before the development of the questionnaire. The pretest was done on 5% of the sample on University students selected outside of the study area to check the cultural sensitivity and clarity of the items which helps to address content validity The training was given to data collectors and supervisors on roles and responsibilities of data collectors and supervisors, the purpose of the study, contents of questionnaires, data collection techniques, meanings of each question and data recording techniques.
Exploratory principal component analysis (PCA) was done to address the construct of the issue of construct validity. The PCA; assumed Varimax rotation with Kaiser normalization for which factor loading less than 0.40 was considered to retain items on their respective factors. On top; a reliability test was conducted to ensure internal consistency. The Cronbach alpha value of greater than or equal to 0.7 was regarded as an acceptable level (Table 1).

Measurements and operational definitions
The study assessed demographic variables including age, sex, religion, class year, and group membership. A pre-tested semi-structured self-administered CAGE (Cut down, Annoyed, Guilty, and Eye-opener)-AID instrument was used to measure the respondent's psychoactive substance abuse [16].

Operational Definitions
Intention towards quitting psychoactive substance abuse is respondent's report of likely to quit psychoactive substance abuse. It was measured using nine items with five points of Likert scale. The nine items were summed up and used for analysis.

Attitude (A)
It is the evaluative feeling of respondents about the advantages, importance, and usefulness of quitting psychoactive substance abuse. It was measured by using nine items on five-point semantic differential scales. The nine direct attitude items were summed up and used for further analysis.

Subjective norm (SN)
It is the respondent's perception of whether important individuals or groups approve/disapprove psychoactive substance abuse. It was measured by using nine items with a five-point Likert scale. But one item was removed through factor analysis. The remaining eight subjective norm items were summed up and used for further analysis.

Perceived behavioral control (PBC)
Any environmental or situational factors that inhibit or facilitate respondents to quit psychoactive substance abuse. This was measured using nine items with five points on the semantic differential scale. The nine items were summed up and used for further analysis.

Psychoactive Substance abuse (PSA)
Item responses on the CAGE were scored 0 for "no" and 1 for "yes"; with a higher score indicating substance use problems. A respondent with a CAGE-AID total score of ≥ 2 was considered to be psychoactive substance abuse. assumption of the theory of planned behavior were followed for analysis. Accordingly; a multiple logistic regression analysis was performed to predict intention to quit psychoactive substance abuse.
A p-value of less than 0.05 was used to indicate a significant association.

Ethical Consideration
The study obtained ethical clearance from an institutional review board of Jimma University College of Health Sciences. A letter of support was obtained from Arbaminch University. An information sheet was attached to each questionnaire to provide the study details and rights of the study participants.
Written informed consent was obtained from the study participants in their halls during data collection. A consent form was attached to the study questionnaire. The data collectors gave orientation to the study participants about the need to read the consent form and put their signature before proceeding to each item in the study questionnaire. Data were kept anonymous and confidential during all stages of the study.

Results
Background characteristics of psychoactive substance abusers Data were obtained from a total of 778 study participants with a response rate of 92.07%.

Socio-demographic factors associated with Psychoactive Substance Abuse
After bivariate analysis, multiple logistic regression analysis was performed with all the socio-demographic variables significantly associated with the outcome variable. Crude Odds Ratio (COR) of the bivariate analysis is also displayed in   norms to quitting psychoactive substance abuse were more than two times likely to intended quitting it than those respondents with unsupportive subjective norms. Besides, the participants' intentions to quit psychoactive substance abuse were also significantly associated with positive Perceived Behavioral Control (PBC). Respondents who had positive PBC were six times more likely to quit psychoactive substance abuse (Adjusted Odds Ratio (AOR) = 6.16, 95%confidence intervals, CI [3.75, 10.14], P = 0.000) when compared with those respondents with negative PBC (Table 5). In this study, the current prevalence rate for overall psychoactive abuse among undergraduate students was 44.6%. This finding is similar to previous studies conducted among Debremarkos and Hawassa universities (35.5%); which are situated in southern and North-west of Ethiopia, respectively [17,18]. However, the psychoactive abuse prevalence of this study is lower than the studies done among students of Haramaya (62.4%) and Diredawa (60%) universities, which are located in South-Eastern and Eastern parts of Ethiopia [19,20].  [17].
This study found that male undergraduate students were two times more likely to abuse psychoactive substances than females. This finding is supported by previous researchers [17,18,20]. On the other hand, the study showed that older age participants had more than twenty times of odds of abusing psychoactive substances compared to younger ones; which is supported by a study done in Nigerian University students [6]. Moreover, this study reported that compared to first-year students, year two, year three, year four and year five and above students had almost two, three, four, and six times, respectively, significant odds of psychoactive substance abuse. This shows that the rate of psychoactive substance abuse increases as the student's year of study increases. The result is supported by a study done among Haramaya University students [20]. However, this finding is contradicted by studies done among Sao Paulo University students [25] which indicated that a significant magnitude of psychoactive abuse was observed among first-year students. This difference could have resulted from cultural differences.
In this study, the constructs of the theory of planned behavior were found as significant predictors of the study participants' intentions to quit Psychoactive Substance Abuse (PSA). That is students with a positive attitude to quit PSA were almost two times more likely to quit PSA than those students with negative attitude ones. This finding is similar to studies done in the UK and South Africa [21,22]. This implies that changing attitude serves as a baseline for making the intention of the students to quit psychoactive substance abuse successfully. Moreover, students with a negative attitude toward quitting PSA experience difficulty to quit PSA.
On the other hand, the study found that undergraduate students, who reported supportive subjective norms to quit psychoactive substance abuse, had more than two times odds of intention to quit PSA than those students with unsupportive subjective norms, which is supported by previous researches done in developed countries [21,22,23]. This indicates that unless students develop effective or supportive subjective norms to quitting PSA, their effort to quit PSA would not be effective. Furthermore, in this study, undergraduate students with poor Perceived Behavior Control (PBC) were six times less likely to quit PSA compared to those students who had better PBC.
This is similar to previous studies done among the USA, UK, Norway, and South African undergraduate students [21,22,23,24]. This result shows that, as one helps PSA students to increase PBC, their likelihood to quit PSA would be possible.

Conclusions
Therefore, the study concluded that psychoactive substance abuse is common among males, older age, senior years of study students. Besides, those university students with a positive attitude, supportive subjective norm and positive perceived behavioral control toward quitting psychoactive substance abuse are more likely to quit abusing the psychoactive substance.
The ways forward based on the finding of this study are as follow; Behavioral change communication strategy should be developed focusing toward developing a positive attitude, supportive subjective norm, and positive perceived behavioral control by segmenting audiences based on their age, sex and years of study in the university.
This implies that changing attitude serves as a baseline for making the intention of the students to quit substance abuse successfully. Moreover, students with the negative attitude toward quitting substance abuse experience difficulty to quit substance abuse than positive intennders .This study also shows that increase in perceived behavioral control contribute to increasing the intention to quit smoking. We strongly acknowledge the College of Health Sciences Ethical Review Board for timely reviewing and giving us ethical clearance timely. We also acknowledge Jimma University Research and Publication Office. We also acknowledge Arbaminch University for permitting to carry out this study. Finally, our deep gratitude goes to students for their participation to provide us valuable information without which this cannot at all be possible.

Funding
The work was supported by grants from Jimma University, College of Health Science Ethiopia, for academic purposes. The funders had no impact on the design, conduct, and reporting of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Availability of data and materials
All data have been included in the manuscript, however, upon request, we can offer SPSS data are available both hard copy and electronically.

Authors' contributions
The authors' responsibilities were as follows: MSM formulated the study hypothesis together with LAG ATG, GKA and HHW performed the statistical analyses and contributed to the first and final draft of the manuscript. MS, LAG, GKA HHW, and ATG contributed to the interpretation of the study results and the first and final draft of the manuscript. Conceptual frame work as applied to the present study. Abbreviations: SD variables=sociodemographic variables, PBC=perceived behavioral control