Life Time Prevalence of Khat Chewing and Its Socio Demographic Correlates Among Adults Age 15-49 Years in Ethiopia: A Population Based Study Using the 2016 Demographic and Health Survey Data

Background: Khat chewing has been practiced from ancient by people in the Eastern part of Africa, the Arabian, Peninsula and other parts of the world. In Ethiopia, khat chewing is becoming habitual and the proportion of people chewing khat has signicantly risen over the years and chewers’ population in Ethiopia is now 16% from the country’s population The main aim of this study was to provide national data on life time prevalence of khat chewing and associated factors that will serve as evidence for policy and planning and as baseline data for further studies. Methods: The data for this study was extracted from the 2016 EDHS. The 2016 EDHS is the fourth and most recent in the Demographic and Health Survey series in Ethiopia. Socio demographic variables were selected based on their availability in the dataset Our analysis included all men and women age 15-49 years which resulted in a total weighted sample of 27,289 Descriptive statistics were employed to show the distribution of socio-demographic characteristics Logistic regression model was used to determine the true association between chat chewing and basic socio-demographic factors Results: Of the total sample of 27289 of men and women age 15-49 years at the time of survey, 18.3% (n = 5006) have life time khat chewing in Ethiopia, About 71.7% of the variation in the outcome variable (khat chewing) is explained by the independent variables included in model Men and women in the 15-19 age group 9.952 (AOR9.952 95% CI 6.156- 16.091) and Men and women age 15-49 years in urban areas 34.040 (AOR 34.040; 95% CI: 21.028--55.105) were found to be major contributing factors to the khat chewing Conclusions Younger age and urban residence had a statistically signicant association with khat chewing. Therefore, to effectively control khat chewing in Ethiopia, Creating awareness and increasing knowledge on the harmful effects of khat chewing are recommended. A particular attention should be given to young adolescent and urban areas


Introduction
Khat chewing has been practiced from ancient by people in the Eastern part of Africa, the Arabian, Peninsula and other parts of the world (1)(2)(3)(4) In Ethiopia the proportion of people chewing khat has signi cantly risen over the years and chewers' population in Ethiopia is now 16% from the country's population (5) In Ethiopia, khat has started to rapidly replace the precious cereal, coffee, fruits and other crops found in the highlands of Ethiopia. Farmers prefer khat due to different reasons including, it's pro tability as a cash crop than others, less vulnerability to drought, and less labor power cost required for its cultivation.
However, khat producing farmers in Ethiopia start consuming khat and this culture is also continued expanding to the nearby secondary schools and urban dwellers (6) The Magnitude of students' khat use in Ethiopia ranges from 13.4% to 41% for lifetime Youths' substance use contributes to the creation of a community with; substance use dependence, juvenile delinquencies, crimes, socio-economic and other public health problems. (7) In Ethiopia, studies conducted among students of Jimma University showed that the current prevalence of khat chewing was 30.8% (8) Moreover, in Ethiopia, 42% of university instructors were lifetime khat chewers (9) Besides, other studies have also presented that the use of khat was signi cantly associated with age, gender and place of residence (10) Similarly, a study in Gondar town revealed that the prevalence of khat chewing was high with statistically signi cant associations with sex, religion, and monthly income (11) A 2011 report from the Ethiopian Demographic and Health (EDHS) survey showed khat chewing was more common in the Eastern, Central and Northeastern parts of the country; the highest wealth index quintile, older age group, unskilled workforce, rural residents, exposure to mass media and administrative regions were factors statistically associated with khat chewing practice (12) Literature has revealed that a number of factors cause the increased khat consumption in different regions of Ethiopia. Among them are normalization in the community, social mobility to most khat chewing community, perceived non -side effect, affordability, type of occupation and availability of khat leaf in the whole year (12,13).
To assist policy formation for coping with all forms of drug abuse in speci c risk groups and the general population of Ethiopia, epidemiological studies are needed to identify risk groups and patterns of drug use behavior (14) the active production stage, country labor force economic production, and chewers' livelihood situation remains questionable. This implies reducing number of chewers through identifying and reducing determinants is essential.
The main aim of this study was to provide national data on life time prevalence of khat chewing and socio demographic factors associated with it and the ndings of this study will serve as evidence for policy and planning, and as baseline data for further studies.

Methods
Data source, sampling and data collection The data for this study was extracted from the 2016 EDHS. The 2016 EDHS is the fourth and most recent in the Demographic and Health Survey series in Ethiopia [15]. The survey was conducted in nine regional states and two city administrations of Ethiopia [15]. Further details on sampling strategy can be found in the DHS manual [15].
A total of 16,583 eligible women and 11,606 eligible men between 15 and 49 years were approached to be interviewed. A response rate of 95% was observed with 15,683 women completing the interviews and response rate 86% among 11,606 men interviewed. The interviews included several standard questionnaires recording information ranging from basic socio-demographic information to detailed bio-medical information.
Our analysis included all men and women age 15-49 years which resulted in a total weighted sample of 27,289

Outcome variable
Life time prevalence of Khat chewing: The proportion of men and women age 15-49 years who had ever chewed Khat in their life time According to EDHS all men and women age 15-49 years asked whether they ever chewed chat or not (1 if they ever chew chat, 0 otherwise).
Number of living children ("1", "1-2", "3-4" and "5+") , Literacy ("Cannot read at all ", "Can read part/whole sentence" and "Other") Household factors included household wealth index (categorized as "poorest", "poorer", "middle", "richer" and "richest"), The household wealth index was calculated using scores based on household assets with analyses conducted by the National Population Commission and Inner City Fund (ICF) International based on a methodology developed from previous DHSs [16, 17] and using methods recommended by the World Bank Poverty Network and United Nations International Children's Emergency Fund (UNICEF) [18].
Community level factors recorded were the place of residence ("rural" or "urban") and geographical region.

Statistical analysis
Sampling weights provided with the EDHS dataset were used during analysis. Further details on sample weights can be found in the EDHS report [15].
Descriptive statistics were employed to show the distribution of background characteristics. We used logistic regression model to determine the true association between chat chewing and basic socio-demographic factors .Both unadjusted and adjusted odds\ ratios (ORs) were reported with 95% con dence intervals (95% CI). Besides, diagnostic tests were done, particularly goodness of t of the model by the Hosmer and Lemeshow test; (where p-value of 0.875 was found), The Cronbach's alpha result of the variables is 0.900 The Nagelkerke R Square shows that about 71.7% of the variation in the outcome variable (chat chewing ) is explained by this logistic model The overall accuracy of this model to predict subjects who ever chew chat (with a predicted probability of 0.5 or greater) is 89.4% All analyses were performed using statistical software SPSS (Version 16.0).

Ethics approval
This study is a secondary analysis of publicly available dataset where permission was obtained through registering with the DHS website and therefore no ethics approval was required.

Result Baseline characteristics
Of the total sample of 27289 of men and women 15-49 years at the time of survey, 18.3% (n = 5006) had life time prevalence of khat chewing ( Table 3).
As summarized in Table 1 (35) is also higher compared to this nding Furthermore, the possible explanations for the observed differences in khat chewing could be due to differences in sample characteristics, in the de nitions used by studies. In our study life time prevalence of Khat use was measured by asking whether they ever chew chat in their previous life and others used de ne Khat use as "using of Khat for the previous one year or one month" and methodological differences.

Socio demographic factors associated with life time prevalence of khat chewing
In our study the life time prevalence of khat chewing was not statistically signi cantly higher in males compared with females similar to ndings from 2015 national Non-communicable diseases STEPS survey (25).
According to our ndings life time prevalence of khat chewing in the general population of Ethiopia was 26.7 % among men and 12.1 % among women of 15-49 years which is similar with EDHS 2011 27.3% among men and 11.0% among women of 15-49 years [26.].
In our study age and area of residence signi cantly associated with khat chewing contrarily with study in Southwestern Saudi Arabia (41) In this study an increase in one-year in age has 9.952 (AOR9.952 95% CI 6.156-16.091) times decrease in odds of chat chewing which is similar to previous studies (8 -9, 21, 27,38,41-43).
This study is contrarily with previous studies [12,48,21,39) Many factors increase the risk of khat chewing during adolescence, including socioeconomic status, neighborhood, cultural context, peer in uence, teachers' in uence and perhaps most importantly, family in uences (44).
It is reported that social acceptability of khat chewing and socialization of this habit increase the likelihood of adolescents adopting the behaviour in Jazan Region (45). For Yemenis, khat may be less of a drug than a medium for socialization (4).
This fall in the age of initiation of khat chewing indicates the failure of prevention strategies (46).
Teenagers who want to try new things and can be convinced by their friends and may try to chew khat for the purpose of relaxation (28).
This indicates that the more educated groups who represent the most productive sections of the society are affected by the khat chewing habit (8).
This showed that the above ages are in the age group called teenage in which those who are in this period want to try everything by themselves and can be exposed to different kinds of substances (9,43). The most frequent reasons for continuing chewing khat were promoting dialogue and social discussion, making the chewer feel refreshed, more energetic, alert and attentive (41).
Similar claims of positive physiological aspects to khat chewing and strong energizing effect of workers have been reported elsewhere (47).
It implies older individuals may be deciding to wait for not chewing in order to deal with their family cases unlike younger that may be sensitive to do what they observe in their life and khat chew.
In this study residence had signi cant association with men and women 15-49 years living in urban areas were 34.04 times higher odds of chat chewing (AOR 34.040; 95% CI: 21.028--55.105) compared to men and women 15-49 years who had live in rural areas which is similar to previous studies (25,32,42,49) and contrarily to studies (12,33).
In this study Higher prevalence in urban observed because from no educated respondents (10701) majority of 54.0% (5779) respondents in urban residence have no education.
According to previous study education is a protective factor for current khat chewing. Participants who are in the no education group are more likely to chew khat than those who are educated (25) Lower educational status was found to be a signi cant independent predictor of current khat chewing (37).
The study conducted from the Jazan region, Saudi Arabia, which showed that illiterates were at higher odds of chewing khat [50].
The reason could be uneducated men would have a lack of information on the negative consequences of khat on their health [51].
In our study age and residence signi cantly associated with life time prevalence of khat chewing and this is similar with the previous study that reported khat chewing was associated with age and residence [52].

Limitations Of The Study
The cross sectional nature of the study design might not show the cause and effect relationships between the explanatory variables and Khat use. Furthermore, Khat use has a social taboo, in which participants might under report their experience and this may introduce social desirability bias.

Conclusion
Younger age (15)(16)(17)(18)(19) and urban residence had a statistically signi cant association with life time prevalence of khat chewing. Therefore, to effectively control khat chewing in Ethiopia, Creating awareness and increasing knowledge on the harmful effects of khat chewing are recommended. A particular attention should be given to young adolescent and urban areas.