Health-Related Quality Of Life And Its Determinants Among Recreational Drug Users In A Rural Area In Cameroon: A Cross-Sectional Study

This study was aimed to evaluate the health-related quality of life (HRQoL) and its drivers among recreational drug users, compared to non-users using WHOQOL-BREF. A total of 246 recreational drug users and 141 non-recreational drug users were recruited using consecutive sampling of adults in the community. Socio-demographic data, data related to recreational drug use and HRQoL were collected. Data were compared using t-test, analysis of variance and chi-square test. Determinants of HRQoL were obtained using multivariate regression models. recreational drug users and non-recreational drug users using Pearson’s chi-square or Fisher’s exact test. Mean quality of life scores across various domains were compared using independent t-test or one-way ANOVA. We used multivariate linear regression models to determine factors independently associated with WHOQOL-BREF scores. Statistical signicance was set at p < 0.05. used, years of drug use, pack years of smoking, age and average monthly income each independently inuenced the HRQoL of participants. To the best of our knowledge, this study is the rst of its kind in Cameroon to provide evidence of diminished HRQoL among recreational drug users in Cameroon. This could serve as basis for appropriate health promotion and sensitization programs to curb the use of recreational drugs which are proven to be detrimental to the health of its users.

functions. It is also thought to extend to the person's perception of health correlates like health risks, social support, cultural beliefs and economic status [16][17][18].
Recreational drug use and the health effects of recreational drug use have been shown to affect the HRQoL of individuals [19,20]. In Cameroon, several studies [15,[21][22][23][24] have been carried out to evaluate the QoL of people living with chronic health conditions. However, no study has been carried out to assess the QoL of recreational drug users in Cameroon. Our study lls this gap by evaluating the HRQoL and factors affecting the HRQoL of recreational drug users compared to non-users of recreational drugs in Cameroon.

Study design and setting
This was a community-based, observational, cross-sectional study. This study was conducted from March 2021 to May 2021 in Mamfe. Mamfe is a border town in the Southwest Region of Cameroon that is about 74 km away from Nigeria. Mamfe has a population of about 34,225 inhabitants spread over a surface area of 744 square kilometers (population density 46 persons/km 2 ). Mamfe is one of the areas affected by the ongoing socio-political crisis in Cameroon [25,26].

Sampling technique and study participants
A target sample size of 374 was obtained using a sample size calculator [27]. A margin of error of ± 5%, con dence level of 95% and a 50% response distribution were used. A population of 13,690 people was used since about 40% of the 34,225 inhabitants of Mamfe are adults [26], this study had 387 participants.
Consecutive sampling was used to recruit all individuals aged 18 years and above, that are permanent residents of Mamfe or have lived in Mamfe for at least 12 months and consented to the study. We excluded adults who were sick at the time of the study, those with chronic diseases, did not understand English and those with physical or mental disability.

De nition of terms and variables
Recreational drugs were de ned as legal and illegal drugs used without medical supervision [1]. By this de nition, alcohol, cigarettes, opioids and other illicit drugs were considered as creational drugs in this study A recreational drug user was de ned as someone who has consumed any recreational drug over the past 12 months [28]. A single question was used to assess this. There is evidence that using a single question for this purpose is valid for screening and evaluation of recreational drugs use [29]. The list of drugs included; alcohol, cigarettes, shisha, cannabis, cocaine, amphetamines, heroin, ecstasy, tramadol, diazepam and sleeping pills, lysergic acid diethylamide (LSD), erection enhancing drugs such as sildena l. A non-recreational drug user was de ned as an individual that has never used drugs for recreational purposes.
Units of alcohol consumed per week was calculated as 5% x volume of beer (in ml) consumed per week/1000 [30]. The average concentration of alcohol in alcoholic beer in Cameroon is 5%.
Physical type of employment generally referred to unskilled jobs such as farming, laborer, and other activities that involves mass lifting of > 20 kg. Non-physical type employment referred to skilled jobs and other employment types with mass lifting of < 20 kg [31].

Study procedures and data collection
Individuals who met the eligibility criteria and consented to the study were interviewed using a pretested structured questionnaire. A doorto-door approach was used to locate participants. To avoid double counting, each individual was asked if they had lled a similar questionnaire prior to recruitment for the study. Literate persons were allowed to ll the questionnaire by themselves after receiving instructions on how to ll the questionnaire. A face-to-face interview was done for illiterate people. Data collected were sociodemographic information, information on the use of recreational drugs and quality of life assessment of participants. Questionnaire was available in English.
The WHOQOL-BREF questionnaire [32] was used to assess the health-related quality of life (HRQoL) of participants. The WHOQOL-BREF tool is a generic self-report HRQoL questionnaire. It was designed to be cross-culturally applicable and has been used in clinical practice and research to assess health outcomes, follow-up progression of a disease and compare health states. Compared to other HRQoL evaluation tools such as Short Form 36, WHOQOL-BREF was found to have good-to-excellent psychometric properties across health states [33,34]. Data management and data analysis Data collected were entered into Microsoft excel 2016, were cleaned, exported and was analyzed using Statistical Package for Social Sciences (SPSS v20). Continuous variables were summarized using mean and standard deviation. Categorical variables were summarized using counts and percentages. Sociodemographic variables were compared between recreational drug users and non-recreational drug users using Pearson's chi-square or Fisher's exact test. Mean quality of life scores across various domains were compared using independent t-test or one-way ANOVA. We used multivariate linear regression models to determine factors independently associated with WHOQOL-BREF scores. Statistical signi cance was set at p < 0.05.

Results
A total of 246 recreational drug users and 141 non-recreational drug users were recruited for this study. The mean age of participants was 34.54 years (SD = 10.96), the male to female ratio was 1.10:1, majority of the study population were single (48.70 %) and employed (55.30%). Details of the sociodemographic features of recreational drug users and non-recreational drug users are shown in Table 1. Higher proportion of males (64.23%) compared to females used recreational drugs, people who were single (48.36%), employed (54.07%), have average monthly income of < 50,000 FCFA (50.0%), attained secondary education (45.93%) and those with physical type of employment (48.78%) had higher proportion of recreational drug use.  Table 2 shows WHOQOL-BREF mean domain score differences between recreational drug users and non-users. Compared to recreational drug users, non-recreational drug users had signi cantly better scores across all four domains, as well as signi cantly better overall quality of life (OQOL) and general health satisfaction (GHS). Among recreational drug users, the highest score was in the psychological domain while the environmental and social relationship domains had the lowest scores.  Proportions were compared using independent sample t-test and one-way ANOVA. p < 0.005 indicated signi cant difference. Table 4   income also affected the WHOQOL-BREF domain scores. After adjustments, increasing age predicted better PHD but poorer GHS, use of recreational drug was associated with poorer PSD and END. As the years of recreational drug use increased the SRD, OQOL and GHS worsened. Using multiple recreational drugs predicted poorer PHD, PSD, SRD and OQOL. Higher pack years of smoking was associated with poorer PSD, SRD and OQOL. Being internally displaced predicted poorer END. And higher monthly income positively in uenced PHD, PSD, END and OQOL.
Our study demonstrated that non-recreational drug users have signi cantly better mean scores across WHOQOL-BREF domains compared to non-users, this is in line with other studies [36][37][38] carried out in western countries. Unlike other studies [36][37][38] in which the psychological domain was the most impaired among recreational drug users, our study showed that the environmental domain of the WHOQOL-BREF was the most impaired amongst drug users. This could be due to the fact that this study was carried out in an area with an ongoing civil war, people living in war zones will likely assess their living environment to be unsafe and unhealthy [39]. Even among nonrecreational drug users in this study, the environmental domain had the least score.
The study by Domingo-Salvany et al [40] as well as other western studies [15,[34][35][36] clearly demonstrated that QOL of drug users is made worse by consumption of multiple recreational drugs, longer years of recreational drug use, older age, low average monthly income and low level of education, our ndings in this study are similar to what was reported by these studies. The lower QOL of drug users compared to non-users cannot only be explained by duration, number or amount of drugs use but also by the negative effects of drug use in several areas of their lives with varying severity [38].
In this study, females had superior mean WHOQOL-BREF domain scores when compared to men. This differs from other studies [36,40] where females were reported to have poorer QOL. The difference could be due to the fact that far lower proportion (less than half) of women in this study used recreational drugs compared to the other studies and most (over 75%) of the men in this study were drug users. Hence there were fewer females with the effect of recreational drug use on their health.
After controlling for other factors, number of recreational drugs used was the only factor independently associated with worse physical health score, while monthly income independently predicted better PHD, monthly income was also associated with better PSD, END and OQOL after controlling for other factors. This is similar to ndings by Moreira et al in Brazil. According to this study, people with low monthly income were more likely to have poor QOL independent of other factors such as use of recreational drugs [36].
Use of recreational drugs, number of recreational drugs use, years of recreational drug use and pack years of smoking each independently predicted poorer PSD and/or SRD. This nding is similar to other studies in Africa and western countries [15,[36][37][38]. Drug users have been shown to have high prevalence of psychiatric disorders which independently in uence their psychological and overall QOL [38].
In this study, apart from average monthly income which positively in uence the END, use of recreational drugs and whether an individual is internally displaced or not each independently predicted poor environmental health after controlling for other factors. In another study [36], use of recreational did not affect the END scores. Probable loss of perception of problems related to the environment was suggested as the reason for high END scores among users. In our study being internally displaced and the ongoing sociopolitical crisis in the setting of this study heavily impaired the environmental health of participants.
Our study had some limitations; we used a cross-sectional design which impaired our ability to determine causality which would have been possible with a prospective cohort design. Our ndings should be generalized with caution as they likely re ect the situation of a rural area that is affected by civil war. In addition, we did not explicitly assess if there were other ongoing events in the lives of participants that could in uenced their responses other than use of recreational drugs. Furthermore, all measures of the WHOQOL-BREF were based on selfreports, the veracity of the responses of individuals cannot be controlled. Finally, there are no population modalities for the use of WHO-BREF in Cameroon. The lack of reference for Cameroon limited our ability to precisely analyse health outcomes.
We however reduced some of the limitations, by choosing a widely validated tool that was developed to be applied across different cultures and allows for comparisons throughout various settings. Future studies to develop a tool that is adapted to assess HRQoL for our environment could go a long way to improve the evaluation of the impact of recreational drug use on the HRQoL of individuals in this environment.

Conclusions
Our ndings suggest that, recreational drugs impedes the HRQoL of its users. Number of recreational drugs used, years of drug use, pack years of smoking, age and average monthly income each independently in uenced the HRQoL of participants. To the best of our knowledge, this study is the rst of its kind in Cameroon to provide evidence of diminished HRQoL among recreational drug users in Cameroon. This could serve as basis for appropriate health promotion and sensitization programs to curb the use of recreational drugs which are proven to be detrimental to the health of its users.