Substances use and its association with sociodemographic, family and environment-related factors among technical and vocational education and training College Students in Ataye, Ethiopia, 2019.

Background: substance use is prevalent in Ethiopia. Substance use can have several health problems that are potentially harmful in educational performance, social issues, psychological and physical wellbeing; especially on youth and adolescents. This study aimed to determine the prevalence of lifetime and last one-month substance use and its associated factors among technical and vocational education and training College Students (TVET) in Ataye town. Methods: an institution based cross-sectional study was conducted. Participants were selected by using simple random sampling technique. Chi-square with its p-value was used to identify correlates for each substance use. Bivariate and multivariate binary logistic regression analysis was performed to identify associated factors after controlling cofounding. Odds ratio with their 95% confidence interval, and P < 0.05 was used to declare the significance of associated factors. Results: A total of 483 individuals were participated, which was a response rate of 94%. The prevalence of lifetime substance use was 32.5% (95% CI: 28.2, 36.5). The prevalence of last month's substance use was 21.9% (95% CI= 18.2, 25.5). Among lifetime users, the majority 98(25.5%) were chewed Khat; followed by alcohol drinking 75(19.5%). Cigarettes, cannabis, and cocaine users were 15.3%, 2.5%, and 7.2% respectively. Among last month's substance users, the same proportions (21.9%) chewed Khat; followed by alcohol drinking, (16.6%) and cigarette smoking, (15.3%). Of last month's substance users, 1.2% and 3.3% of students used Cannabis and cocaine respectively. Using multivariate binary logistic regression, Being male (AOR=2.2, 95%CI: 2.3, 3.84), Being from divorced family (AOR=4.1,95%CI: 1.1, 5.8), Living > 20 years in the town (AOR=3.45,95%CI: 1.18,10.1), had family member substance user (AOR=2.5, 95%CI: 1.1, 5.8), had intimate friend substance user (AOR=5.3,95%CI:

lower the prevalence.

Background
Substance use has the capability of affecting the state of the body and the mind by either depressing or stimulating the central nervous system or producing other biochemical harmful effects (1). An estimated 250 million people (around 5%) of the global adult population use drugs at least once in their lifetime as studied in 2015. The more worrisome fact is about 29.5 million drug users, or 0.6% of the global adult population suffer from drug use disorders (2).
World Drug Report (2018) revealed that more than a quarter of a billion people use drugs globally.
The actual number of people who use drugs increased by 20 million people from 2015 to 2016.
Roughly 450,000 people died as a result of drug use in 2015, according to the world health organization (WHO). Of those deaths, 167,750 were directly associated with drug use disorders (mainly overdoses), (3).
According to the 2016 Ethiopian demographic and health survey (EDHS) report, 35% of women and about ha1f of men (46%) reported drinking alcohol at some point in their lives. The percentage of women who chewed Khat for 6 days or more in the last 30 days increased from 43% in 2011 to 65% in 2016. Among men, the proportion increased from 56-64%. The use of tobacco increases with age among men and reaches a peak at age 40-44 years. There is wide regional variation in cigarette smoking ranging from less than 1% of men in Amara to 13% in Dire Dewa and 18% in Somali (4).
Drug use is associated with adverse health consequences. Problems of substance use seem to be rapidly growing concern globally. It is also a major threat among youth in college and university. Some of the researchers have shown that the use of drugs by school-going youth does not only decreases their academic performance; but also makes them vulnerable to crime. Furthermore, drug use exposes them to health risks among other numerous problems (5).
Substance use is a common phenomenon among college and university students in Ethiopia.
Generally, substance use is one of the most serious health threats that potentially harm students of college and university in many countries and the general population at large (6). The use of drugs among adolescents can be harmful leading to failure in academic performance, increased risk of acquiring HIV/AIDS, and other STIs. Substance use can lead to lethargy, hopelessness and insomnia (7). It has also been noted that family background, student pocket money, peer pressure, accessibility of substances and customs of society at large contribute to the increased rate of substance use among college students. Most students, staff at an institution of higher education and youths in the community are considered at high risk of substance use (8).
The problem of substance use has historically been linked to Ataye town due to the accessibility of substances. Substance use habit is a common phenomenon in the study area. Despite the fact that such problems are one of the top health risks among college students, there are no adequate studies conducted to explore the prevalence and associated factor of substance use in TVET college students.
The findings of this study will be useful to the education bureau and school administrations to develop strategies to mitigate students' substance use behavior. The study findings also may help curriculum developers in formulating and incorporating psycho-education programs in TVET College which address the risk of substance use. School managers also may benefit from findings so that they may come up with policies and strategies for controlling this potentially dangerous habit.

Specific objectives
To determine the prevalence of last month substance use among Ataye TVET college students To determine the prevalence of lifetime substance use among Ataye TVET college students To identify associated factors with substance use among Ataye TVET college students Methods Study Area, design and period The study was conducted in Ataye TVET College, North Showa zone which is found in Amara Regional state of Ethiopia. The study area located 272 km from Addis Ababa and 130 km from Debre Berhan town. Orthodox, Muslim, and Protestant followers are the major inhabitants found in the study area.
At Ataye TVET College, there are 1,433 students enrolled in the academic year. Out of these, 683 were male, and 750 were female students. An institution-based cross-sectional study was conducted to assess the prevalence of last month and lifetime substance use and associated factors among TVET College students from 1 st March to last May 2019.

Population
Source population: All regular Ataye TVET College students.
Study population: All regular Ataye TVET College students and who were available during the study period.
Sample size calculation and Sampling procedure The sample size was calculated using a single population proportion formula. A 15.36% rate of substance use was taken from the related study (9), with a margin of error 5%, confidence level 95%, and non-response rate 10%. The final sample size became 514 students. Ataye TVET College has 1,433 students enrolled in the study academic year. There are 9 departments from the first year to the third year. The departments are Agriculture, hotel kitchen operation, Electricity, Auto engine service, Garment, Surveying, Construction, Metalwork and Road construction. From the 9 departments, five departments were selected by using by lottery method. The total sample size was distributed proportionally to the selected department based on the total number of students in each year. The study participants were selected by using simple random sampling technique by generating numbers using Open EPI software.

Eligibility criteria
Inclusion criteria: all students at Ataye TVET College.
Exclusion criteria: Students could not be reached in 3 visits during the data collection period were excluded.

Study variables
Dependent variables: lifetime Substance use and last month Substance use Independent variables Socio-demographic characteristics: (age, sex, residence, economic status, education status, religion, ethnicity, and, living status, mother education level, father education level, and friend use of substance, lake of family supervision, family conflict, family history of substance use, family income, availability of substance, source of money, grade level, peer pressure, marital status of family.

Operational definition
Lifetime substance Use: use of one or more substances for nonmedical purposes after joining the Ataye TVET College.
Last month Substance use: use of one or more substances for nonmedical purposes in the past 30 days prior to the data collection period.
Licit substances: drugs that are not prohibited to sell, buy and use among above 18 years old persons (i.e. alcohol, Khat, and cigarette) during the study period.
Illicit drugs: drugs which are prohibited to sell, buy and use among all age groups (rather than alcohol, Khat, and cigarette) during the study period.
Data collection tools and procedures Data were collected by using a structured and pretested self-administered questionnaire. The questionnaire included variables like a habit of substance use, socio-demographic and economic variables, the practice of substance use, the reason for substance use, and family history of substance use. The questionnaires were prepared in English then translated to the local language (Amharic). Out of nine departments, five departments (55%) were selected by using the lottery method. Participants were selected by using simple random sampling technique.

Data quality control
To keep the quality of data, data collectors and supervisors were trained for one day regarding the necessary explanation about the current research. Data were collected by five trained diploma nurses with close supervision. A pre-test was conducted on 5% (n=24) students among similar study populations from non-participating departments before 2 weeks of the actual data collection period.
The collected data were reviewed and checked for completeness before data entry. The data were properly coded, and entered to Epi Info 3.5.1 and exported to SPSS V. 21 for analysis.

Ethical consideration
Ethical clearance was obtained from the Debre Berhan University ethical review committee. A cooperation letter to each study health institution was written and a permission letter was taken. Oral informed consent was taken from each study participants who were aged 18 years and above. Assent was taken from participants who were aged less than 18 years. Written informed consent was taken from participants' family/legal guardian who aged < 18 years.

Results
Sociodemographic characteristics of students A total of 483 students were participated, which was a response rate of 94%. The median age of the students was 20 years with an Interquartile range of 3, (Q1 = 18, Q3 = 21 years). Among the sociodemographic variables, the nearly equal proportion was observed in terms of sex (49.7% male and 50.3% female). The majority, 346 (71.6%) students were orthodox in religion and the remaining 137

Family-related factors
Almost half, 277 (57.4%), and 251 (52%) of student's mother and father were not attended modern education respectively. Sixty percent of student's parents were lived in an urban area, and 212 (44%) was a farmer in occupation. Nearly eighty percent of students' parents were married and nearly forty percent, 208 (43.1%) student's parent were lived for 1-5 years in the Ataye town (Table 1). reported that the reason for their substance use was due to a lack of recreational area in the town.
The minimum of students, 63 (13%) were started substance use due to peer influence. Furthermore, students reported other driving environmental factors for their lifetime substance use (Fig. 1).
Prevalence of last month substance use and its correlates Alcohol, Khat and Cigarette use in the last month and its variation across study subjects' characteristics were compared by using chi-square with its p-value. The result of this study showed that being in different age groups had contribution for prevalence of last month licit substance use.
Being from urban and rural in residency were statistically insignificant for all the three listed drugs (alcohol, Khat, and Cigarette). This means a students in these subcategories were equally practiced substances used in the last month. Living alone and living with others had a contribution to the variation of last month's prevalence of alcohol drinking (X 2 = 7.8, p-value = 0.02) and Khat chewing (X 2 = 16, p-value = 0.00); but not for cigarette smoking (X 2 = 3.3, p-value = 0.2). Other students' characteristics were statistically significant correlates with last month's substance use. This indicated that students with different predictor variables were not equally practiced drugs in the last month (Table 2). were not statistically significant in association with last month's cocaine use. This showed students in these subcategories were equally practiced cocaine use in the last month (Table 3). Table 3 Last month illicit drugs use and its correlation with students and family characteristics among Ataye  Key: * p-value < 0.05, ** p-value = 0.00, X2 = chi-square Lifetime cannabis use variation was observed among students' differences in living with and family monthly income. For lifetime cocaine use, variation was observed in sex, academic level, and living with differences (Table 5).  (Table 6). Table 6 Bivariate and multivariate analysis to identify associated factors with lifetime drug use among Ataye Only two studies; one from Hawassa University (10) and another study from Gondar University (11) reported similar prevalence (around 24%) of lifetime Khat chewing.
Prevalence of lifetime Khat chewing in the current study was lower than studies from Haramaya (12), and Jimma (9) universities. The possible reason might be due to the availability of Khat in Haramaya and Jimma town is more prevalent than the current study area. Especially, Haramaya dwellers linked Khat to the economy of the household and chewed Khat as a habit (13). This allows students to be easily exposed and practiced Khat. Prevalence of lifetime Khat chewing was higher than studies done among Addis Ababa University, Debre Berhan University, and Ataye town students (9,14,15). A possible explanation for the high prevalence of lifetime Khat chewing in Ataye extends to social and environmental differences. First of all, Khat is cultivated around Ataye town that could make it easy to access by students. All these factors can contribute to the practice of Khat chewing among Ataye TVET students compared to the above Ethiopian Universities.
Last month Khat chewing prevalence was lower than the study from the same study area (9) and Hawassa University (8). Except for the study from south Iran (16), both last month and lifetime drinking of alcohol was lower than the studies from Jimma, Gondar, Debre Berhan, Hawassa University, and Woreta town (14,(17)(18)(19). This may be underreported due to social desirability and increased abstinence rate in the past 30 days. And also, since the data collections were done inside the teaching classroom, those students with addiction behaviors may remain outside the classroom because of their academic and living lifestyle. This can potentially introduce selection bias and result in a lower estimate of substance use prevalence (10).
Lifetime and last month smoking of cigarette were lower than studies from southern Iran (16) and Jimma University (15). The possible explanation might be due to the health behavior of the students and the target population's age difference.
Male students were two times more likely to use a substance in a lifetime (after joining college) as compared with female students. The association is in agreement with studies done in Haramaya University (12) and Jimma University (17). In fact, male students use substances than females due to cultural and hormonal differences.
Having substance user friends and family member were more likely to be exposed for substance use in a lifetime as compared with who have no substance user friend and family. The association is supported by studies done in Addis Ababa University (14), Debre Berhan University (15), Hawassa University (10), Grate Accra metropolis (20), and Woreta Town (19). This might be due to, they may let students familiarize substances and adopt utilization thereby reducing the subjective norm and perceived risk perception of students.
Being from a divorced family also had a significant contribution to substance use as compared with students from married families. The study from Kuwait supports this association (21). There are many factors that increase a young person's likelihood of substance use. Among them, parental divorce is the main factor. Parental conflicts and lack of supervision from parents is a known factor for young's health problem.
Easily availability of the substance was a statistically significant factor for lifetime substance use as compared with students from less substance accessibility areas. The possible reason might be, increased substance availability is associated with increased use. In the study area, licit drugs are easily available; but not known about illicit drugs (cannabis and cocaine). At the study area (Ataye) and catchment areas, khat is cultivated by the community and this may put the study subjects to a greater risk of exposure.
Living 20 years and above in Ataye town was also more likely to be exposed to the substances as compared with those who lived 1-5 years. This might be due to, living more years in one town might increase the exposure of the study participants to substances. In fact, more years are needed to assimilate the community habit of substance use; even if it is two decades.
Generalizability: The external validity of the study was managed during a sample size calculation, sampling procedures, and techniques, training of data collectors and data quality control sections.

Limitations of the study
The current study did not assess substance abuse and substance use disorder. There is no validity assurance for underreporting of substance use. Students are more likely to deny their utilization behavior because of social desirability bias.

Conclusions
Prevalence of last month and lifetime substance use among Ataye TVET College students were analogous with other studies done in Ethiopia. Students who are aged less than 18 years were also reported substance use. Cannabis and cocaine are illegal drugs in Ethiopia. But, the reported proportion of these illegal drug use was significant and needs government attention

Recommendations
It is advisable if the college administrators work together with town administrators to mitigate the problem including closing substance use homes around the school. Overall, Substance use among adolescents should get further emphasis to lower the prevalence. Availability of data and material: the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate: Ethical clearance was obtained from the Debre Berhan University ethical review committee. A permission letter was written to each study health institution and a permission letter was taken. Oral informed consent was taken from each study participant who is aged 18 years and above. Assent was taken from participants who are aged less than 18 years.
Written consent was taken from participants' family/legal guardian aged < 18 years.
Consent for publication: the manuscript did not contain individuals' person detailed data in any form.
Competing Interest: The authors declare that they have no conflicts of interest.
Funding: The research was not funded by any funder. The cost of the design of the study and data collection, analysis, and interpretation of data and writing the manuscript covered by the study authors.

Figure 1
Self-reported environmental reasons for substance use among Ataye TVET students, Ethiopia, in 2019.