Chewing khat and risky sexual behavior among residents of Bahir Dar City administration, Northwest Ethiopia

Khat is a natural stimulant from the Catha edulis plant which is grown in southern Arabia and Eastern Africa, and primarily in the countries of Ethiopia, Somalia, Kenya and Yemen [1–3]. It is a bushy plant whose leaves are chewed for social and psychological reasons due to the active psycho-stimulant substance known as cathinone which affects central nervous system (CNS) like amphetamine. The leaves are freshly stripped from the trees at dawn and rapidly distributed in regions where Khat chewing is widespread since cathinone can be found only in fresh Catha edulis leaves [1, 2, 4].

An estimated 10 million people worldwide chew khat, and commonly found and consumed in the southwestern part of Arabian Peninsula and East Africa, and immigrant communities living in Europe and North America [3, 5, 6]. Similarly, Ethiopia is hardly hit by khat consumption. Both institution and community based studies done in Jimma have indicated the high prevalence of khat use seeing that 46 and 37.8%, respectively, chewed khat at least once in their lifetime [7, 8]. Previously, khat was mainly cultivated and chewed in limited, particularly eastern, part of the country. Nowadays, however, it is grown and consumed in all parts of the country including Amhara region [2, 9].

The recent sharp increment in khat consumption brings socio-economic, psychological and physical health sequelae of individuals involved. Though chewing khat is reported to induce a state of elation and feelings of increased alertness and arousal, at the end of a khat session, users may experience a depressed mood, irritability, loss of appetite, gastritis and peptic ulcer disease and difficulty sleeping [3, 10].

In addition, different studies in Ethiopia have revealed that the habit of chewing khat leads to a fragment of family, and multiple sexual practices. The habit, thus, could fuel spread of sexually transmitted infections (STIs) due to the associated risky sexual behaviors like having casual sex, unprotected sex and early initiation of sexual activity reported among chewers [11–15].

The number of khat users has increased in Ethiopia during recent decades and the habit has become popular in all sections of the society. Although khat is a legal substance in the country, it can be an entry point to the use of other illicit drugs, and risky sexual practices. This has to be made aware to local governmental officials and other concerned bodies to reduce its consequences. However, despite the prevalence of khat use and its effects were studied at institution basis, still, there is limited knowledge on khat chewing and its relation with risky sexual behaviors at the community level. Therefore, it is imperative to do this research determining the prevalence of lifetime and current chewing khat and its relation to risky sexual behaviors among residents of Bahir Dar City administration, Northwest Ethiopia. The findings will assist health care providers and program planners focusing their approach in the management of health problems related to khat consumption.

The increment in the number of khat chewers globally needs a better understanding of the local burden and most common influencing factors and its relation to risky sexual behaviors. This paper has found that life time and current prevalence of chewing khat were 25.7 and 19.5%, respectively. The life time prevalence of the current study is in line with the findings in Eastern Ethiopia (24.2%) [17] and Ethiopian University students (24%) [18]. Nevertheless, this study has revealed relatively higher lifetime and current chewing khat prevalence than the result from Jimma, Ataye, Lalibela, Gondar and Dera parts of Ethiopia (14.3–17.9% and 13.3–14.2%, respectively) [19–22].

The higher prevalence of khat chewing in the current study and Eastern Ethiopia might be due to the fact that these two sites cultivate the substance leading availability of khat with least cost. Easily accessibility of substance and its low cost exposes the community to develop habits of chewing [16, 18, 23].

The lifetime (42.0%) and current (32.5%) prevalence of chewing khat in Gondar town Northwest Ethiopia [24] were higher than 25.7 and 19.5%, respectively, from the current study. The difference might be due to the difference in the study participants. The study done in Gondar consisted only college students, but the current study included both students and other participants in the community. According to the similar study, students who perceived that khat helps to study better were more likely to chew khat than those who did not perceive [18]. This has shown that students were expected to use khat to enhance their academic performance which is kept in a report from Kenya [25]. This is also supported by the current study indicating that being students increased the habit of chewing khat compared to government employees.

In this study, the most commonly mentioned reasons for chewing khat are fighting depressed mood (56.9%) followed by getting concentration (45.6%). Similar findings were also documented from the study done in Gondar town northwest Ethiopia where concentration during the study and getting entertainment and relaxation were reported by 62.3 and 36.9% of participants, respectively [24]. In addition, religious purpose, peer pressure, passing time and socialization were also mentioned as reasons of chewing khat in the current and previous studies done in University of Gondar and Dera district [9, 18].

The present study showed that males had around six times more probability of chewing khat than females which is consistent with studies in Ethiopia and Saudi Arabia [9, 17, 20, 22, 26, 27]. This might be due to the fact that the number of substance users is high among males than females, and it is accepted to use substances among males in different parts of the world including Ethiopia. In other words, this could be due to the culture which discourages the habit of chewing khat among females. This is also supported by the study done in Kenya showing that respondents strongly agreed on luxuriated habit of Khat chewing more boys than girls [25].

Likewise, occupation, marital status, and average monthly income were the most important parameters either to increase or hinder the chance of chewing khat in this study which is in line with other study done elsewhere [28]. Merchants and students practiced the habit near to five times more than government employees. The students might use the substance for getting concentration during the study and due to peer pressure since students pass their time with their friends. Students used chewing khat to study better than not used [18]. Having friends with khat chewing and peer pressure were confirmed as they scupper the people for a habit of chewing. More than half of respondents under the influence of their peer used substances [29]. The current study has also revealed that merchants were more likely to chew khat than government employees which is in line with the report from Dera district, Ethiopia [9].

The study participants with higher incomes in this study were more likely for chewing khat than to those with relatively lower incomes. This thought has concurred with the study done in Yemen [30] and University students of Ethiopia [17]. Furthermore, study participants with highest family socio-economic status were more prone to substance use [22]. This might be due to lack/shortage of money to buy khat since diversion of income for purchase of khat results in neglecting the family needs leading to family conflicts and discords. Thus, participants with low income will be restricted from chewing khat.

Khat chewing brings socio-economic and physical health problem on chewers. The current study participants mentioned that they lost their money performed their work poorly and damaged their objects to get khat which is in coherent with results reported from northwest Ethiopia [31, 32]. Moreover, khat chewing influenced their social relationships with their friends, parents, and others. This might be due to the reason that they lost their time on chewing khat resulting in a shortage of time to participate in any social related activities. For instance, chewers lost an average of three and half hours for single chewing practice without considering the time lost for buying and preparation according to this study. In addition, this study found that the chewers’ physical health including exposure to STIs is also damaged due to their practice.

This study has revealed that chewing khat has a significant association to increase odds of developing risky sexual behaviors which are endorsed by other study done in Dilla University, Ethiopia [33]. Studies were done in the United Kingdom and Ghana have shown the increased impact of substance use on taking of risky sexual behaviors though they assessed the effect of other substances rather than khat [26, 34]. These risky sexual behaviors included having extramarital sexual partners; ever had sexual intercourse; and self-reported STIs. The significant relation of initiation of sexual intercourse and chewing khat was similarly reported in Dilla University, Ethiopia [33]. Moreover, those substance users were actively engaged with multiple sexual partners according to the study done in Ghana among homeless children and adolescents [26]. Chewing khat and alcohol drinking habit could also place the married individuals to have extramarital sexual relationships according to the present result which may facilitate the transmission of STIs. Similar findings reported from Bahir Dar University, Ethiopia resulting in having multiple sexual partners and sex with commercial sex workers, and sexual intercourse for money generation [35].

The self-reported STIs might be due to their inconsistent use of condoms during their sexual activity which was documented in the current study reporting that near to six percent of the participants engaged in unprotected sex. Similarly, another study conducted in Ghana [26] is in line with the present study. Although the study was not done on khat chewers, the finding from Sao Paulo Brazil has supported the effect of substance use on inconsistent utilization of condom [36]. The current study also documented not using of condom among alcohol drinkers during their last sexual activity that may increase the prevalence of self-reported STIs since alcohol drinking increased risky sexual behavior as affirmed by a study in Pawe District and Bahir Dar University, Ethiopia [35, 37]. It is not statistically significant; however, khat chewers have shown slightly increased odds of having sexual intercourse within last 12 months and inconsistent use of a condom.

In general, the discussion, implication, and conclusion of this study were performed by considering the limitation of the study. The relation of khat chewing with risky sexual behaviors was not possible to make clear cause-effect relationship since the study design was cross-sectional. In addition, the data were collected using questionnaires adopted and adapted by reviewing different published articles indicating not assessed by a standard tool which was another limitation. Psychological morbidity was not screened suggesting that the paper did not address the effect of chewing khat on psychological health.

Khat chewing is relatively prevalent among community residents in the study area which is significantly associated with male gender, being a merchant, student and having an average of more than 1001 EBR monthly income. This study also examined that khat use was found to be a risk factor for the development of risky sexual behaviors exposing them at risk for acquisition and transmission of STIs. Therefore, creating community awareness to address the problem of khat chewing and related consequences was recommended to health professionals and volunteer community health workers. The result demands an integrated strategy to effectively control both khat use and related STIs. In addition, further studies are needed using longitudinal study design to explore the actual interactions between khat use and risky sexual behaviors among community residents.