Intention to Stop Khat Chewing and Associated Factors among Khat Chewers in Dessie City, North Eastern Ethiopia

AIDS: Acquired Immune Deficiency Syndrome; CR: Consciousness Rising; CGPA: Cumulative Grade Point Average; DR: Dramatic Relief; EDHS: Ethiopian Demographic and Health Survey; ER: Environmental Reevaluation; ERB: Ethical Review Board; FGD: Focus Group Discussion; GM: Gram; HIV: Human Immune Virus; KG: Kilo Gram; MOH: Minster of Health; NGO: Non-Governmental Organization; SDS: Substance Dependency Scale; SE: Self Efficacy; SL: Social Liberation; SPSS: Statistical Package for Social Science; PAS: Psychoactive Substance; UK: United Kingdom; US: United States of America; USD: United State Dollar

Khat (Catha edulisForsk) is a flowering evergreen plant that contains psychoactive substance known as Cathinone which have effect on individual’s consciousness, behavior, mood and thinking processes [1].

It was first identified by a botanist whose name was Forskal in 1762 in Yemen and he categorized the plant in group spinosa. However, currently it is botanically classified under the family Celastriaceae [2]. Khat goes by numerous names: Khat, qat, chat, qaadka, kusessalahinmiraa, tohai, tschat, Abyssinian tea, African tea, African salad, and brown cows [3]. It is chewable leaf with a mild narcotic effect [4]. The environment determines the chemical profile of khat leaves and it has psychoactive central stimulation substance Cathinone. Khat chewing is common in Horn of Africa and the Arabian Peninsula where it has a thousand of year history. Currently, Khat use is spread worldwide like pandemic and more than 10 million people in the world use khat [2,5].

In addition, WHO reported that khat use related to Cardiovascular, respiratory, reproductive and central nervous system problems? Likely, the study conducted in Jimma Zone, South Western Ethiopia also indicated that khat chewing negatively affected labor productivity reduced sexual activity and associated to risky behaviors. It also revealed 53% of khat chewers accustomed to smoking.

Furthermore, the other study conducted in southern nation nationalities and peoples and Oromia regional state concluded that Khat chewing is a risk behavior for the spread of HIV infection [2,5,6]. Because of this, the World Health Organization is considers Khat chewing as risk factor of health. Khat chewing is illegal in US, UK and other developed countries [1,4,5]. A Literature review on Substance Abuse and Mental Health in Africa reveled that Africa particularly, Ethiopia confront with the burden related to Khat chewing [7].

Despite this fact, Ethiopia is the world’s largest producer of khat, which is the country’s fastest growing export. The negative effect of Khat is less emphasized in Ethiopia (Figure 1) [2,8].

Figure 1: Conceptual frame work on factors associated with intention to stop khat chewing among khat chewers in Dessie city, North eastern Ethiopia, developed by modifying conceptual frame work for quitting from substance use in Diredawa town Ethiopia study.

Justification of the study

Currently, it is difficult to frighten or punish someone out of substance dependence, but with the right sort of evidence based treatment, dependent users can change their behavior and be active and productive members of the community. Intention is critical to bring behavioral change.

Despite numerous studies on khat were conducted in Ethiopia, there is no study that investigated Khat chewer’s intention to stop khat chewing and associated factors using trans-theoretical model. Therefore, this study aims to provide information that help to set stage based intervention and provide base line data for further research.

General objective

The general purpose of this study was to assess intention to stop khat chewing and associated factors among Khat chewers in Dessie city, north eastern Ethiopia.

Specific objectives

To determine the level of intention to stop khat chewing among Khat chewers in Dessie city, north eastern Ethiopia.

To identify associated factors of intention to stop Khat chewing among khat chewers in Dessie city, north eastern Ethiopia Administration.

Socio-demographic characteristics of the study participants

From a total of 762 participants recruited, 726 participated in the study while 36 unwilling to participate in the study, yielding the response rate of 95.26%. Among the 726 study participants, 579 (79.8%) were males. The mean age of the respondents was 27.6 (SD ± 0.2) years (Table 1).

Table 1: Distribution of the socio-demographic characteristics of Khat chewers in Dessie, Ethiopia; 2015 (n=726).

About two third of the respondents, 488 (67.2%) were followers of Muslim, 218(30%) were orthodox Christianity, 10 (1.4%) were protestants and 8 (1.1%) were catholic. The predominant ethnic group was Amhara 671 (92.4%) followed by Tigere 36 (5%).

Majority of the respondents 510 (70.2%) were single, 267 (36.8%) of the study participants had not any job and 92 (12.7%) were students.

Out of the total participants, 497 (68.47%) had intention to stop khat chewing at least within the next six months. Majority of the study participants 325 (44.77%) were on preparation stage, 172 (23.7%) were on contemplation stage and the rest 229 (31.54%) were on pre contemplation stage (Table 2).

Table 2: Stage of changes among Khat chewers in Dessie city, Ethiopia; 2015.

Socio demographic, khat chewing and related history

The mean age for initiation of Khat chewing was 19.23 (SD ± 0.2) years. The average length of Khat chewing was 5.8 (SD ± 0.19) years. Two hundred nineteen (30.2%) participants were chewed khat on daily bases and 109 (15%) were chewed 4-6 days per week.

Factors associated with intention to stop khat chewing

Bivariate analysis was done to establish statistical significance and strength of the association between each factors and dependent variable (intention to stop Khat chewing). All factors which were significant during the bivariate analysis were passed through multivariate analysis.

The overall significant predictors of intention to stop khat chewing during the multivariate analysis at p<0.05 were educational level, sex, frequency of khat chewing, perceived barriers (withdrawal effect), relative economic status, process of changes (consciousness raising, dramatic relief, self-re-evaluation, social liberation), self-efficacy and decisional balance. Occupation, age, religion, marital status, peer pressure and environmental re-evaluation process of change were factors that had not significant association on multivariate analysis.

Females were 1.76 times more likely to have the intention to stop khat chewing (P=0.03 AOR=1.76, 95% CI; 1.2-2.5) when compared to males. Individuals who have attended preparatory, level and diploma educational level were 2 times more likely to have the intention to stop khat chewing (P=0.00 AOR=2.0, 95% CI; 1.02-3.8) compared to those Khat chewers who were unable to read and write.

Respondents who thought their Khat chewer friends had the same economic status with them were 29% (AOR=0.71, 95% CI; 0.21-0.92) less likely to have intention to stop Khat chewing when compared to those Khat chewers who thought they had less economic status than their chewer friends.

Khat chewers who had not withdrawal effect were 2.6 more likely to have intention to stop khat chewing (AOR=2.6, 95% CI; 1.3-5.2) when compared to those who had withdrawal effect and frequent Khat chewers were 94% less likely to have intention than those who chewed khat sometimes [(AOR=0.06 , 95% CI; 0.02-0.14)] (Table 3).

Table 3: Factors associated to intention to stop Khat chewing among Khat chewers in Dessie city, Ethiopia; 2015.

Processes of change

In this study, Individuals who had medium consciousness raising score were 2.6 times more likely to have the intention to quit Khat chewing than individuals with low consciousness raising score, [P=0.003 AOR=2.7, (95% CI: 1.1, 6.6)].

Participants in high dramatic relief process of change were 4 times more likely to have intention to stop Khat chewing than their counterparts, [AOR=4.1 (1.5-11.0)] (Table 4).

Table 4: Relationship of the covariates of process of change with intention to stop khat chewing among Khat chewers in Dessie city, Ethiopia; 2015.

Individuals with medium environmental reevaluation were 2.4 times more likely to have the intention to quit Khat chewing than low self-reevaluation individuals, [AOR=2.4 (1.1-5.4)].

Individuals with medium self-reevaluation were 5 times more likely to have the intention to quit Khat chewing than low self-reevaluation individuals, [AOR=4.8 (2.15-10.8) ] (Table 4).

Self-efficacy not to chew khat

The confidence of the Khat chewers not to chew khat on different places and situations that can aggravate chewing behavior demonstrated that only 199 (27.1%) had high self-efficacy whereas 406 (55.9%) had low confidence not to chew Khat. The rest 122 (16.8%) were in an intermediate situation not to chew on those places and circumstances. self-efficacy had negative significant association with intention to stop Khat chewing.

Decisional balance to stop khat chewing

For the majority 370 (51.0%) of the respondents, the mean score of pros of chewing outweighs the cons score (Positive decisional balance) whereas for 272 (37.5%) of them, the mean score of cons of chewing outweighs the pros (had negative decisional balance). Individuals who had positive decisional balance score were 4 times more likely to have the intention to quit Khat chewing than individuals with negative decisional balance. [P=000, AOR=4.1 (2.1-7.8)].

Qualitative result

A total of 21 individuals were involved in 3 focus group discussions (FGDs) and 5 in-depth interviews (IDI) conducted. The results are presented simultaneously.

Community perception about Khat chewing

An in-depth interview was made with a lecturer and researcher in Wollo university sociology department. He had lived in Dessie since 1980 E.C. He noted that the historical development of khat and its use was limited to eastern parts of Ethiopia mainly Harrar, where khat is said to originated and used. Currently, khat is cultivated for commercial purposes in all corners of the country and it has increasing a number of users in all major cities. He noted that the major factor that can be cited for the increase in the production of khat is its economic benefit to the khat farmers. At present khat is the 3rd exportable foreign currency earner for the country that brings. Near to Dessie city there are many privately owned co-operatives and enterprises which possess legal license to export khat in Bahir Dar and Haike. This indicates that khat is well accepted by the community and this trend is on the increase.

The lecturer was of the opinion that khat chewing is a deeply rooted cultural practice in most places of the Dessie city and it has its own ceremonial rituals.

Almost all participants of in depth were agreed on the increasing trend of khat use in Dessie city. An elder participant of in-depth interview reported that Khat chewing was discouraged in past but now it seems normal. Some of the in depth interview participants also said that it was better to chew Khat rather than drunk Alcohol.

Related to the spread of Khat use in Dessie city, one of the focused group participants said “I have tried not to be friends with those who use khat; however, it is becoming difficult to do as many people have converted to khat chewers in Dessie city”.

Khat chewing can instigate guilt and self-contradictory notions among the users despite their free-will choice. Interestingly, respondents who chew khat do not want to be labeled as “chewers”. One respondent put it like this: “I chew khat once in a while but I don’t consider myself a chewer”. Another reported that “I never want my kids see me chew”. Another respondent declared that “I am proud not to depend on khat ever my life and Khat never hold mood on me rather I hold mood on Khat”.

There are people who chose to chew khat openly in the streets, under shades and verandas, as opposed to people who do it behind closed doors. The choice of where to chew relates to self-image and dignity. There are people who consider khat undignified.

Most participants of FGDs were not happy related to their Khat chewing habit. A 27 years old male focus group discussion participant explained that although it is very difficult, it is better to stop khat chewing and said “eating bread is better than chewing match”. Another 22 years old female FGDs participant stated that she was embarrassed about her chewing habit. Most of the participant agreed on even though khat is economically powerful, socially evil.

Almost all of the FGDs and in- depth interview participants agreed that even though khat is a relaxing substance, yet we should decolonize ourselves from khat.

Who uses khat?

FGDs and In-depth interviews Participants were estimated that the prevalence of khat use among the community members was varied. Most said Khat use was higher among men than women.

FGDs and In-depth interview participants noted that although, it was generally agreed Muslims used khat more commonly the number of orthodox Christians Khat users was high. “A 23 year old male Muslim FGDs participant explained that Muslims chew khat to be alert and to avoid sleeping during praying. Another 20 year old male Muslim said”, khat is not related religion, rather Muslims chew Khat just to be alert and avoid sleep.

Most of participant mentioned that the most frequent users of Khat were jobless youths, higher education students, street children and Drivers.

One of the respondent stated that he is chewing Khat because of there is no places to spent his spare time and said, “I have nothing to do, with the boring day, except to gather with my friends to chew khat”.

Can khat chewers stop Khat chewing at any time when they want?

Most of the participants agreed that khat was addictive and said that is why most of Khat chewers try to stop repeatedly, but they also fail repeatedly. As declared by most of the participant it very hard for one to control his addiction to khat. One in-depth participant said “One cannot easily say only sit for khat on Sunday or on Saturday. Whenever you get a chance, you want to grab it”.

More than half of FGDs and in-depth interview participants identified a specific withdrawal syndrome upon stopping khat use which leads to high discontinuation rate. One respondent also said “Those who consider Khat not addictive are deluding themselves. It is an addiction that no one can get rid of easily except with God’s help”.

In addition, one FGDs participant explained it is very difficult for us to stop Khat chewing completely and said “In my view, Khat chewer may stop for a while, but never ceases at all”.

On the other hand, some participants reported that they did not believe khat is addictive, and they could limit their khat use to once or twice a week.

Perceived barriers to stop khat chewing

Although some participants related Khat chewing with Muslim religion, as mentioned by majority of the participant’s joblessness is the main barrier to stop Khat chewing. In addition, Participants indicated that the main reason for continuing to chew khat was having substantial leisure time, no hobbies and peer pressure. A 23 year male participant said, “I chew because my friends forced me to chew” and a 24 years male group discussant said “I chew not to disturb my friends’ mood”.

Some FGDs and in-depth interviews participants were described that withdrawal effect also another factor that affects intention to stop Khat chewing. A 26-year-old male respondent from the in-depth interview explained that Khat chewers’ feels headache and fatigability (Ducace) when they stopped to chew Khat and he said that, “I would be paralyze, if I don’t chew Khat.”

Another 27 year old male student respondent from the focus group discussion explained, “I can’t read a line of a passage, unless I chew Khat.”

Furthermore, FGDs and In-depth interview participants suggested that difficulties in detecting and responding to health problems associated with khat use may be compounded by poor health literacy and poor utilization of health services by people who use Khat.

Suggestions to control the spread khat chewing

Participants suggested several ways to reduce the Khat chewing. Some of the points they mentioned were: Educating the community and the government should take measure related to Joblessness. Health professionals should also play a role in educating users about potential harms arising from khat use and means of quitting from khat use

Studies on intention to stop Khat chewing are scarce despite the ever-growing rate of Khat chewing behaviors. A positive finding of this study is the high intention of Khat chewers to stop Khat chewing. This study found that more than half of (68.47%) the study participants had intention to stop Khat chewing. This figure was higher than the studies finding in USA (62%), UK (50%) and Yemen (46%). The higher intention to stop Khat chewing in this study might be explained due to socio cultural variation among study population [9,10].

It also higher than the finding of the studies conducted in Deberemarkos University and Diredawa town. The observed difference might be because of setting difference. On the other hand, this result is consistent with finding of a study done in eastern Ethiopia.

One of the predictors of intention to stop Khat chewing was gender. In this study, there was positive assoction between being females and intention to stop Khat chewing. This finding was in line with studies reported for Deberemarkos, Jimma and Hawassa [11-13]. The possible reason for the observed higher intention to stop Khat chewing among females is due to females were culturally discouraged to chew Khat and cultural acceptance of male practicing Khat chewing.

This result was strengthened by the in-depth interview in this study. During In-depth interview a 21-year old, female, preparatory student and orthodox respondent reported that she felt guilty about her chewing habit and a 48 years old, housewife, Muslim focus group discussant said, “I do not chew Khat in my home, because I feel shame”.

According to this study, education was one of the significant factors that affect Khat chewer intention to stop Khat chewing. Similar difference was reported from community based study conducted in Diredawa which reveled educated individuals were more likely to have intention then the illiterate. The observed difference might be because of educated individual had an opportunities to know the harmful effect of Khat.

Withdrawal effect and frequency Khat chewing were negatively associated with intention to stop khat chewing. These results were also supported by the qualitative part of this study. More than half of FGDs and in-depth interview participants identified a specific withdrawal syndrome upon stopping khat use which leads to high discontinuation rate. One respondent also said “Those who consider Khat not addictive are deluding themselves. It is an addiction that no one can get rid of easily except with God’s help”. A 26-year-old male respondent from the in-depth interview explained that Khat chewers’ feels headache and fatigability (Ducace) when they stopped to chew Khat and he said that, “I would be paralyze, if I don’t chew Khat”. A 27-year-old male student participant in the focus group discussion also explained, “I can’t read a line of a passage, unless I chew Khat”. The observed low intention to stop Khat chewing among frequent Khat chewers and Khat chewers who had withdrawal effect was might be because of habitual use of Khat [5].

In this study, In line with the finding of Diredawa [14], USA [15] and Iran [16] studies, this study result reflected that consciousness raising processes of change significantly associated with intention to stop Khat chewing. This might be due to finding and learning new ideas and facts helps Khat chewers to develop healthy behavioral change.

This study showed that Intention to stop Khat chewing was higher among individuals who were at high dramatic relief process of change than individuals at low dramatic relief process of change, which is in line with the research findings reported for Diredawa town. This might be because of experiencing the negative emotion (fear, anxiety, worry) that along with unhealthy behaviors may leads to Khat chewers to have intention to stop Khat chewing.

Unlike the study in USA, in this study environmental reevaluation process of change was not significantly associated with intention to stop Khat chewing [17]. The difference may be simulated by setting, rules and regulation enforcement difference which may leads this study participants to give less concern on the negative impact of the Khat chewing on social and physical environment. On the other hand, this finding was consistent with study done in Diredawa town which found that there was no significant association between environmental reevaluation process of change and intention to stop substance use.

Intention to stop Khat chewing was found to be 1.7 times more likely among respondents at medium social liberation process of change than Khat chewers at low social liberation process of change. This finding was inconsistent with study done in Diredawa which indicated there was no statistically significant difference between high, medium and low social liberation process of change with intention to stop substance use. The observed difference might be because of socio cultural variation between the study populations.

The other significant factor identified in this study was selfreevaluation process of change. In this study, Intention to stop Khat chewing was found to be 5 times more likely among study participants in medium self-reevaluation process of change as compared to those individuals at low self-reevaluation process of change [(AOR=4.8 (2.1-10.8)]. The gap might be explained because of realizing that the behavior changes are an important part of one’s identity as person helps to develop intention to stop Khat chewing. This finding was consistent with the finding of the studies in Diredawa town and USA.

Unlike study finding in USA, in this study self-efficacy and decisional balance had significant association with intention to stop Khat chewing. For the majority 370 (51.0%) of the respondents, the mean score of pros of chewing outweighs the cons score (Positive decisional balance).

This study indicated that marital status, occupation, religion, peer pressure, negative emotion, environmental reevaluation were not predictors of Khat chewing practice and their association with intention to stop Khat chewing was not statistically significant. Their insignificant association might be due to confounding factors.

Majority of the Khat chewers had the intention to stop Khat chewing. The significant predictors of intention to stop khat chewing were educational level, sex, frequency of khat chewing, perceived barriers(withdrawal effect), relative economic status, process of changes (consciousness raising, dramatic relief, self-re-evaluation, social liberation), self-efficacy and decisional balance.

Occupation, age, religion, marital status, peer pressure and environmental re-evaluation process of change were factors that had not statistically significant association with intention to stop Khat chewing.

Thus, Intention is the key to change and stage based interventions should be taken to raise awareness, clarify misconceptions and to increase confidence on oneself to stop Khat chewing through quit skill training and setting norms not to chew in public places.

A positive finding of this study is the high intention of Khat chewers to stop Khat chewing. Given the high level of interest to stop Khat chewing, the investigator o of the study believe the opportunities of Khat chewing cessation in the health facilities is underutilized. However, even when assuming a willingness to assist Khat chewers to stop chewing, it is my view the necessary skill and medication unavailable. Based on this study finding the following recommendation was given.

Policy, strategies, program management

• The government should break the silence and establish clear polices and strategies about Khat chewing that aligned to the national youth polices and strategies.

• Increase involvement of civil societies, faith-based and community-based organizations in awareness creation about Khat pandemic.

• Promote health care provider-client (Chewers who want to stop Khat chewing) partnerships.

• Promote a supportive substance-free environment.

• Give special attention to Khat chewers.

Interventions

• Address misconceptions about Khat chewing with special focus to Youth Khat chewers.

• Apply stage based intervention.

• Build self-efficacy and peer resistance skills among the youth Khat Chewers.

• Address risk groups (higher education students, psychiatric patients, street children, Jobless youths).

• Involve religious institutions, and community-based organizations to clarify misconception.

Research capacity

• Improve research capacities in areas of prevention, intervention, and monitoring and evaluation youth free from Khat programs.

• Strengthen multi-disciplinary research with special focus on involving health education and promotion studies.

We are very grateful to our college staff members for unreserved guidance and constructive suggestions and comments from the stage of proposal development to this end. We would like to thank University of Gondar for supporting the budget which required for this research. Finally our deepest gratitude goes to Dessie city Health Office, which helped and allowed us in collecting and gathering data.

ME; carried out the research drafting, design, statistical analysis and interpretation as well as coordinating all activities in the research, GA; participate in the sequence alignment and drafted a manuscript, BK; participates in the design of the study and performs statistical analysis.

Funding: University of Gondar

Conflict of interest: None declared

Ethical approval: Approval and permission was sought from Ethical Review Board of College of Medicine and Health Sciences of University of Gondar.