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• Published: 13 November 2021

Risk and protective factors of drug abuse among adolescents: a systematic review

• Azmawati Mohammed Nawi 1 ,
• Rozmi Ismail 2 ,
• Fauziah Ibrahim 2 ,
• Mohd Rohaizat Hassan 1 ,
• Mohd Rizal Abdul Manaf 1 ,
• Noh Amit 3 ,
• Norhayati Ibrahim 3 &
• Nurul Shafini Shafurdin 2  

BMC Public Health volume  21 , Article number:  2088 ( 2021 ) Cite this article

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Drug abuse is detrimental, and excessive drug usage is a worldwide problem. Drug usage typically begins during adolescence. Factors for drug abuse include a variety of protective and risk factors. Hence, this systematic review aimed to determine the risk and protective factors of drug abuse among adolescents worldwide.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted for the review which utilized three main journal databases, namely PubMed, EBSCOhost, and Web of Science. Tobacco addiction and alcohol abuse were excluded in this review. Retrieved citations were screened, and the data were extracted based on strict inclusion and exclusion criteria. Inclusion criteria include the article being full text, published from the year 2016 until 2020 and provided via open access resource or subscribed to by the institution. Quality assessment was done using Mixed Methods Appraisal Tools (MMAT) version 2018 to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken.

Out of 425 articles identified, 22 quantitative articles and one qualitative article were included in the final review. Both the risk and protective factors obtained were categorized into three main domains: individual, family, and community factors. The individual risk factors identified were traits of high impulsivity; rebelliousness; emotional regulation impairment, low religious, pain catastrophic, homework completeness, total screen time and alexithymia; the experience of maltreatment or a negative upbringing; having psychiatric disorders such as conduct problems and major depressive disorder; previous e-cigarette exposure; behavioral addiction; low-perceived risk; high-perceived drug accessibility; and high-attitude to use synthetic drugs. The familial risk factors were prenatal maternal smoking; poor maternal psychological control; low parental education; negligence; poor supervision; uncontrolled pocket money; and the presence of substance-using family members. One community risk factor reported was having peers who abuse drugs. The protective factors determined were individual traits of optimism; a high level of mindfulness; having social phobia; having strong beliefs against substance abuse; the desire to maintain one’s health; high paternal awareness of drug abuse; school connectedness; structured activity and having strong religious beliefs.

The outcomes of this review suggest a complex interaction between a multitude of factors influencing adolescent drug abuse. Therefore, successful adolescent drug abuse prevention programs will require extensive work at all levels of domains.

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Introduction

Drug abuse is a global problem; 5.6% of the global population aged 15–64 years used drugs at least once during 2016 [ 1 ]. The usage of drugs among younger people has been shown to be higher than that among older people for most drugs. Drug abuse is also on the rise in many ASEAN (Association of Southeast Asian Nations) countries, especially among young males between 15 and 30 years of age. The increased burden due to drug abuse among adolescents and young adults was shown by the Global Burden of Disease (GBD) study in 2013 [ 2 ]. About 14% of the total health burden in young men is caused by alcohol and drug abuse. Younger people are also more likely to die from substance use disorders [ 3 ], and cannabis is the drug of choice among such users [ 4 ].

Adolescents are the group of people most prone to addiction [ 5 ]. The critical age of initiation of drug use begins during the adolescent period, and the maximum usage of drugs occurs among young people aged 18–25 years old [ 1 ]. During this period, adolescents have a strong inclination toward experimentation, curiosity, susceptibility to peer pressure, rebellion against authority, and poor self-worth, which makes such individuals vulnerable to drug abuse [ 2 ]. During adolescence, the basic development process generally involves changing relations between the individual and the multiple levels of the context within which the young person is accustomed. Variation in the substance and timing of these relations promotes diversity in adolescence and represents sources of risk or protective factors across this life period [ 6 ]. All these factors are crucial to helping young people develop their full potential and attain the best health in the transition to adulthood. Abusing drugs impairs the successful transition to adulthood by impairing the development of critical thinking and the learning of crucial cognitive skills [ 7 ]. Adolescents who abuse drugs are also reported to have higher rates of physical and mental illness and reduced overall health and well-being [ 8 ].

The absence of protective factors and the presence of risk factors predispose adolescents to drug abuse. Some of the risk factors are the presence of early mental and behavioral health problems, peer pressure, poorly equipped schools, poverty, poor parental supervision and relationships, a poor family structure, a lack of opportunities, isolation, gender, and accessibility to drugs [ 9 ]. The protective factors include high self-esteem, religiosity, grit, peer factors, self-control, parental monitoring, academic competence, anti-drug use policies, and strong neighborhood attachment [ 10 , 11 , 12 , 13 , 14 , 15 ].

The majority of previous systematic reviews done worldwide on drug usage focused on the mental, psychological, or social consequences of substance abuse [ 16 , 17 , 18 ], while some focused only on risk and protective factors for the non-medical use of prescription drugs among youths [ 19 ]. A few studies focused only on the risk factors of single drug usage among adolescents [ 20 ]. Therefore, the development of the current systematic review is based on the main research question: What is the current risk and protective factors among adolescent on the involvement with drug abuse? To the best of our knowledge, there is limited evidence from systematic reviews that explores the risk and protective factors among the adolescent population involved in drug abuse. Especially among developing countries, such as those in South East Asia, such research on the risk and protective factors for drug abuse is scarce. Furthermore, this review will shed light on the recent trends of risk and protective factors and provide insight into the main focus factors for prevention and control activities program. Additionally, this review will provide information on how these risk and protective factors change throughout various developmental stages. Therefore, the objective of this systematic review was to determine the risk and protective factors of drug abuse among adolescents worldwide. This paper thus fills in the gaps of previous studies and adds to the existing body of knowledge. In addition, this review may benefit certain parties in developing countries like Malaysia, where the national response to drugs is developing in terms of harm reduction, prison sentences, drug treatments, law enforcement responses, and civil society participation.

This systematic review was conducted using three databases, PubMed, EBSCOhost, and Web of Science, considering the easy access and wide coverage of reliable journals, focusing on the risk and protective factors of drug abuse among adolescents from 2016 until December 2020. The search was limited to the last 5 years to focus only on the most recent findings related to risk and protective factors. The search strategy employed was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) checklist.

A preliminary search was conducted to identify appropriate keywords and determine whether this review was feasible. Subsequently, the related keywords were searched using online thesauruses, online dictionaries, and online encyclopedias. These keywords were verified and validated by an academic professor at the National University of Malaysia. The keywords used as shown in Table  1 .

Selection criteria

The systematic review process for searching the articles was carried out via the steps shown in Fig.  1 . Firstly, screening was done to remove duplicate articles from the selected search engines. A total of 240 articles were removed in this stage. Titles and abstracts were screened based on the relevancy of the titles to the inclusion and exclusion criteria and the objectives. The inclusion criteria were full text original articles, open access articles or articles subscribed to by the institution, observation and intervention study design and English language articles. The exclusion criteria in this search were (a) case study articles, (b) systematic and narrative review paper articles, (c) non-adolescent-based analyses, (d) non-English articles, and (e) articles focusing on smoking (nicotine) and alcohol-related issues only. A total of 130 articles were excluded after title and abstract screening, leaving 55 articles to be assessed for eligibility. The full text of each article was obtained, and each full article was checked thoroughly to determine if it would fulfil the inclusion criteria and objectives of this study. Each of the authors compared their list of potentially relevant articles and discussed their selections until a final agreement was obtained. A total of 22 articles were accepted to be included in this review. Most of the excluded articles were excluded because the population was not of the target age range—i.e., featuring subjects with an age > 18 years, a cohort born in 1965–1975, or undergraduate college students; the subject matter was not related to the study objective—i.e., assessing the effects on premature mortality, violent behavior, psychiatric illness, individual traits, and personality; type of article such as narrative review and neuropsychiatry review; and because of our inability to obtain the full article—e.g., forthcoming work in 2021. One qualitative article was added to explain the domain related to risk and the protective factors among the adolescents.

PRISMA flow diagram showing the selection of studies on risk and protective factors for drug abuse among adolescents.2.2. Operational Definition

Drug-related substances in this context refer to narcotics, opioids, psychoactive substances, amphetamines, cannabis, ecstasy, heroin, cocaine, hallucinogens, depressants, and stimulants. Drugs of abuse can be either off-label drugs or drugs that are medically prescribed. The two most commonly abused substances not included in this review are nicotine (tobacco) and alcohol. Accordingly, e-cigarettes and nicotine vape were also not included. Further, “adolescence” in this study refers to members of the population aged between 10 to 18 years [ 21 ].

Data extraction tool

All researchers independently extracted information for each article into an Excel spreadsheet. The data were then customized based on their (a) number; (b) year; (c) author and country; (d) titles; (e) study design; (f) type of substance abuse; (g) results—risks and protective factors; and (h) conclusions. A second reviewer crossed-checked the articles assigned to them and provided comments in the table.

Quality assessment tool

By using the Mixed Method Assessment Tool (MMAT version 2018), all articles were critically appraised for their quality by two independent reviewers. This tool has been shown to be useful in systematic reviews encompassing different study designs [ 22 ]. Articles were only selected if both reviewers agreed upon the articles’ quality. Any disagreement between the assigned reviewers was managed by employing a third independent reviewer. All included studies received a rating of “yes” for the questions in the respective domains of the MMAT checklists. Therefore, none of the articles were removed from this review due to poor quality. The Cohen’s kappa (agreement) between the two reviewers was 0.77, indicating moderate agreement [ 23 ].

The initial search found 425 studies for review, but after removing duplicates and applying the criteria listed above, we narrowed the pool to 22 articles, all of which are quantitative in their study design. The studies include three prospective cohort studies [ 24 , 25 , 26 ], one community trial [ 27 ], one case-control study [ 28 ], and nine cross-sectional studies [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. After careful discussion, all reviewer panels agreed to add one qualitative study [ 46 ] to help provide reasoning for the quantitative results. The selected qualitative paper was chosen because it discussed almost all domains on the risk and protective factors found in this review.

A summary of all 23 articles is listed in Table  2 . A majority of the studies (13 articles) were from the United States of America (USA) [ 25 , 26 , 27 , 29 , 30 , 31 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], three studies were from the Asia region [ 32 , 33 , 38 ], four studies were from Europe [ 24 , 28 , 40 , 44 ], and one study was from Latin America [ 35 ], Africa [ 43 ] and Mediterranean [ 45 ]. The number of sample participants varied widely between the studies, ranging from 70 samples (minimum) to 700,178 samples (maximum), while the qualitative paper utilized a total of 100 interviewees. There were a wide range of drugs assessed in the quantitative articles, with marijuana being mentioned in 11 studies, cannabis in five studies, and opioid (six studies). There was also large heterogeneity in terms of the study design, type of drug abused, measurements of outcomes, and analysis techniques used. Therefore, the data were presented descriptively.

After thorough discussion and evaluation, all the findings (both risk and protective factors) from the review were categorized into three main domains: individual factors, family factors, and community factors. The conceptual framework is summarized in Fig.  2 .

Conceptual framework of risk and protective factors related to adolescent drug abuse

DOMAIN: individual factor

Risk factors.

Almost all the articles highlighted significant findings of individual risk factors for adolescent drug abuse. Therefore, our findings for this domain were further broken down into five more sub-domains consisting of personal/individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance history, comorbidity and an individual’s attitude and perception.

Personal/individual traits

Chuang et al. [ 29 ] found that adolescents with high impulsivity traits had a significant positive association with drug addiction. This study also showed that the impulsivity trait alone was an independent risk factor that increased the odds between two to four times for using any drug compared to the non-impulsive group. Another longitudinal study by Guttmannova et al. showed that rebellious traits are positively associated with marijuana drug abuse [ 27 ]. The authors argued that measures of rebelliousness are a good proxy for a youth’s propensity to engage in risky behavior. Nevertheless, Wilson et al. [ 37 ], in a study involving 112 youths undergoing detoxification treatment for opioid abuse, found that a majority of the affected respondents had difficulty in regulating their emotions. The authors found that those with emotional regulation impairment traits became opioid dependent at an earlier age. Apart from that, a case-control study among outpatient youths found that adolescents involved in cannabis abuse had significant alexithymia traits compared to the control population [ 28 ]. Those adolescents scored high in the dimension of Difficulty in Identifying Emotion (DIF), which is one of the key definitions of diagnosing alexithymia. Overall, the adjusted Odds Ratio for DIF in cannabis abuse was 1.11 (95% CI, 1.03–1.20).

Significant negative growth exposure

A history of maltreatment in the past was also shown to have a positive association with adolescent drug abuse. A study found that a history of physical abuse in the past is associated with adolescent drug abuse through a Path Analysis, despite evidence being limited to the female gender [ 25 ]. However, evidence from another study focusing at foster care concluded that any type of maltreatment might result in a prevalence as high as 85.7% for the lifetime use of cannabis and as high as 31.7% for the prevalence of cannabis use within the last 3-months [ 30 ]. The study also found significant latent variables that accounted for drug abuse outcomes, which were chronic physical maltreatment (factor loading of 0.858) and chronic psychological maltreatment (factor loading of 0.825), with an r 2 of 73.6 and 68.1%, respectively. Another study shed light on those living in child welfare service (CWS) [ 35 ]. It was observed through longitudinal measurements that proportions of marijuana usage increased from 9 to 18% after 36 months in CWS. Hence, there is evidence of the possibility of a negative upbringing at such shelters.

Personal psychiatric diagnosis

The robust studies conducted in the USA have deduced that adolescents diagnosed with a conduct problem (CP) have a positive association with marijuana abuse (OR = 1.75 [1.56, 1.96], p  < 0.0001). Furthermore, those with a diagnosis of Major Depressive Disorder (MDD) showed a significant positive association with marijuana abuse.

Previous substance and addiction history

Another study found that exposure to e-cigarettes within the past 30 days is related to an increase in the prevalence of marijuana use and prescription drug use by at least four times in the 8th and 10th grades and by at least three times in the 12th grade [ 34 ]. An association between other behavioral addictions and the development of drug abuse was also studied [ 29 ]. Using a 12-item index to assess potential addictive behaviors [ 39 ], significant associations between drug abuse and the groups with two behavioral addictions (OR = 3.19, 95% CI 1.25,9.77) and three behavioral addictions (OR = 3.46, 95% CI 1.25,9.58) were reported.

Comorbidity

The paper by Dash et al. (2020) highlight adolescent with a disease who needs routine medical pain treatment have higher risk of opioid misuse [ 38 ]. The adolescents who have disorder symptoms may have a risk for opioid misuse despite for the pain intensity.

Individual’s attitudes and perceptions

In a study conducted in three Latin America countries (Argentina, Chile, and Uruguay), it was shown that adolescents with low or no perceived risk of taking marijuana had a higher risk of abuse (OR = 8.22 times, 95% CI 7.56, 10.30) [ 35 ]. This finding is in line with another study that investigated 2002 adolescents and concluded that perceiving the drug as harmless was an independent risk factor that could prospectively predict future marijuana abuse [ 27 ]. Moreover, some youth interviewed perceived that they gained benefits from substance use [ 38 ]. The focus group discussion summarized that the youth felt positive personal motivation and could escape from a negative state by taking drugs. Apart from that, adolescents who had high-perceived availability of drugs in their neighborhoods were more likely to increase their usage of marijuana over time (OR = 11.00, 95% CI 9.11, 13.27) [ 35 ]. A cheap price of the substance and the availability of drug dealers around schools were factors for youth accessibility [ 38 ]. Perceived drug accessibility has also been linked with the authorities’ enforcement programs. The youth perception of a lax community enforcement of laws regarding drug use at all-time points predicted an increase in marijuana use in the subsequent assessment period [ 27 ]. Besides perception, a study examining the attitudes towards synthetic drugs based on 8076 probabilistic samples of Macau students found that the odds of the lifetime use of marijuana was almost three times higher among those with a strong attitude towards the use of synthetic drugs [ 32 ]. In addition, total screen time among the adolescent increase the likelihood of frequent cannabis use. Those who reported daily cannabis use have a mean of 12.56 h of total screen time, compared to a mean of 6.93 h among those who reported no cannabis use. Adolescent with more time on internet use, messaging, playing video games and watching TV/movies were significantly associated with more frequent cannabis use [ 44 ].

Protective factors

Individual traits.

Some individual traits have been determined to protect adolescents from developing drug abuse habits. A study by Marin et al. found that youth with an optimistic trait were less likely to become drug dependent [ 33 ]. In this study involving 1104 Iranian students, it was concluded that a higher optimism score (measured using the Children Attributional Style Questionnaire, CASQ) was a protective factor against illicit drug use (OR = 0.90, 95% CI: 0.85–0.95). Another study found that high levels of mindfulness, measured using the 25-item Child Acceptance and Mindfulness Measure, CAMM, lead to a slower progression toward injectable drug abuse among youth with opioid addiction (1.67 years, p  = .041) [ 37 ]. In addition, the social phobia trait was found to have a negative association with marijuana use (OR = 0.87, 95% CI 0.77–0.97), as suggested [ 31 ].

According to El Kazdouh et al., individuals with a strong belief against substance use and those with a strong desire to maintain their health were more likely to be protected from involvement in drug abuse [ 46 ].

DOMAIN: family factors

The biological factors underlying drug abuse in adolescents have been reported in several studies. Epigenetic studies are considered important, as they can provide a good outline of the potential pre-natal factors that can be targeted at an earlier stage. Expecting mothers who smoke tobacco and alcohol have an indirect link with adolescent substance abuse in later life [ 24 , 39 ]. Moreover, the dynamic relationship between parents and their children may have some profound effects on the child’s growth. Luk et al. examined the mediator effects between parenting style and substance abuse and found the maternal psychological control dimension to be a significant variable [ 26 ]. The mother’s psychological control was two times higher in influencing her children to be involved in substance abuse compared to the other dimension. Conversely, an indirect risk factor towards youth drug abuse was elaborated in a study in which low parental educational level predicted a greater risk of future drug abuse by reducing the youth’s perception of harm [ 27 , 43 ]. Negligence from a parental perspective could also contribute to this problem. According to El Kazdouh et al. [ 46 ], a lack of parental supervision, uncontrolled pocket money spending among children, and the presence of substance-using family members were the most common negligence factors.

While the maternal factors above were shown to be risk factors, the opposite effect was seen when the paternal figure equipped himself with sufficient knowledge. A study found that fathers with good information and awareness were more likely to protect their adolescent children from drug abuse [ 26 ]. El Kazdouh et al. noted that support and advice could be some of the protective factors in this area [ 46 ].

DOMAIN: community factors

• Risk factor

A study in 2017 showed a positive association between adolescent drug abuse and peers who abuse drugs [ 32 , 39 ]. It was estimated that the odds of becoming a lifetime marijuana user was significantly increased by a factor of 2.5 ( p  < 0.001) among peer groups who were taking synthetic drugs. This factor served as peer pressure for youth, who subconsciously had desire to be like the others [ 38 ]. The impact of availability and engagement in structured and unstructured activities also play a role in marijuana use. The findings from Spillane (2000) found that the availability of unstructured activities was associated with increased likelihood of marijuana use [ 42 ].

• Protective factor

Strong religious beliefs integrated into society serve as a crucial protective factor that can prevent adolescents from engaging in drug abuse [ 38 , 45 ]. In addition, the school connectedness and adult support also play a major contribution in the drug use [ 40 ].

The goal of this review was to identify and classify the risks and protective factors that lead adolescents to drug abuse across the three important domains of the individual, family, and community. No findings conflicted with each other, as each of them had their own arguments and justifications. The findings from our review showed that individual factors were the most commonly highlighted. These factors include individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance and addiction history, and an individual’s attitude and perception as risk factors.

Within the individual factor domain, nine articles were found to contribute to the subdomain of personal/ individual traits [ 27 , 28 , 29 , 37 , 38 , 39 , 40 , 43 , 44 ]. Despite the heterogeneity of the study designs and the substances under investigation, all of the papers found statistically significant results for the possible risk factors of adolescent drug abuse. The traits of high impulsivity, rebelliousness, difficulty in regulating emotions, and alexithymia can be considered negative characteristic traits. These adolescents suffer from the inability to self-regulate their emotions, so they tend to externalize their behaviors as a way to avoid or suppress the negative feelings that they are experiencing [ 41 , 47 , 48 ]. On the other hand, engaging in such behaviors could plausibly provide a greater sense of positive emotions and make them feel good [ 49 ]. Apart from that, evidence from a neurophysiological point of view also suggests that the compulsive drive toward drug use is complemented by deficits in impulse control and decision making (impulsive trait) [ 50 ]. A person’s ability in self-control will seriously impaired with continuous drug use and will lead to the hallmark of addiction [ 51 ].

On the other hand, there are articles that reported some individual traits to be protective for adolescents from engaging in drug abuse. Youth with the optimistic trait, a high level of mindfulness, and social phobia were less likely to become drug dependent [ 31 , 33 , 37 ]. All of these articles used different psychometric instruments to classify each individual trait and were mutually exclusive. Therefore, each trait measured the chance of engaging in drug abuse on its own and did not reflect the chance at the end of the spectrum. These findings show that individual traits can be either protective or risk factors for the drugs used among adolescents. Therefore, any adolescent with negative personality traits should be monitored closely by providing health education, motivation, counselling, and emotional support since it can be concluded that negative personality traits are correlated with high risk behaviours such as drug abuse [ 52 ].

Our study also found that a history of maltreatment has a positive association with adolescent drug abuse. Those adolescents with episodes of maltreatment were considered to have negative growth exposure, as their childhoods were negatively affected by traumatic events. Some significant associations were found between maltreatment and adolescent drug abuse, although the former factor was limited to the female gender [ 25 , 30 , 36 ]. One possible reason for the contrasting results between genders is the different sample populations, which only covered child welfare centers [ 36 ] and foster care [ 30 ]. Regardless of the place, maltreatment can happen anywhere depending on the presence of the perpetrators. To date, evidence that concretely links maltreatment and substance abuse remains limited. However, a plausible explanation for this link could be the indirect effects of posttraumatic stress (i.e., a history of maltreatment) leading to substance use [ 53 , 54 ]. These findings highlight the importance of continuous monitoring and follow-ups with adolescents who have a history of maltreatment and who have ever attended a welfare center.

Addiction sometimes leads to another addiction, as described by the findings of several studies [ 29 , 34 ]. An initial study focused on the effects of e-cigarettes in the development of other substance abuse disorders, particularly those related to marijuana, alcohol, and commonly prescribed medications [ 34 ]. The authors found that the use of e-cigarettes can lead to more severe substance addiction [ 55 ], possibly through normalization of the behavior. On the other hand, Chuang et al.’s extensive study in 2017 analyzed the combined effects of either multiple addictions alone or a combination of multiple addictions together with the impulsivity trait [ 29 ]. The outcomes reported were intriguing and provide the opportunity for targeted intervention. The synergistic effects of impulsiveness and three other substance addictions (marijuana, tobacco, and alcohol) substantially increased the likelihood for drug abuse from 3.46 (95%CI 1.25, 9.58) to 10.13 (95% CI 3.95, 25.95). Therefore, proper rehabilitation is an important strategy to ensure that one addiction will not lead to another addiction.

The likelihood for drug abuse increases as the population perceives little or no harmful risks associated with the drugs. On the opposite side of the coin, a greater perceived risk remains a protective factor for marijuana abuse [ 56 ]. However, another study noted that a stronger determinant for adolescent drug abuse was the perceived availability of the drug [ 35 , 57 ]. Looking at the bigger picture, both perceptions corroborate each other and may inform drug use. Another study, on the other hand, reported that there was a decreasing trend of perceived drug risk in conjunction with the increasing usage of drugs [ 58 ]. As more people do drugs, youth may inevitably perceive those drugs as an acceptable norm without any harmful consequences [ 59 ].

In addition, the total spent for screen time also contribute to drug abuse among adolescent [ 43 ]. This scenario has been proven by many researchers on the effect of screen time on the mental health [ 60 ] that leads to the substance use among the adolescent due to the ubiquity of pro-substance use content on the internet. Adolescent with comorbidity who needs medical pain management by opioids also tend to misuse in future. A qualitative exploration on the perspectives among general practitioners concerning the risk of opioid misuse in people with pain, showed pain management by opioids is a default treatment and misuse is not a main problem for the them [ 61 ]. A careful decision on the use of opioids as a pain management should be consider among the adolescents and their understanding is needed.

Within the family factor domain, family structures were found to have both positive and negative associations with drug abuse among adolescents. As described in one study, paternal knowledge was consistently found to be a protective factor against substance abuse [ 26 ]. With sufficient knowledge, the father can serve as the guardian of his family to monitor and protect his children from negative influences [ 62 ]. The work by Luk et al. also reported a positive association of maternal psychological association towards drug abuse (IRR 2.41, p  < 0.05) [ 26 ]. The authors also observed the same effect of paternal psychological control, although it was statistically insignificant. This construct relates to parenting style, and the authors argued that parenting style might have a profound effect on the outcomes under study. While an earlier literature review [ 63 ] also reported such a relationship, a recent study showed a lesser impact [ 64 ] with regards to neglectful parenting styles leading to poorer substance abuse outcomes. Nevertheless, it was highlighted in another study that the adolescents’ perception of a neglectful parenting style increased their odds (OR 2.14, p  = 0.012) of developing alcohol abuse, not the parenting style itself [ 65 ]. Altogether, families play vital roles in adolescents’ risk for engaging in substance abuse [ 66 ]. Therefore, any intervention to impede the initiation of substance use or curb existing substance use among adolescents needs to include parents—especially improving parent–child communication and ensuring that parents monitor their children’s activities.

Finally, the community also contributes to drug abuse among adolescents. As shown by Li et al. [ 32 ] and El Kazdouh et al. [ 46 ], peers exert a certain influence on other teenagers by making them subconsciously want to fit into the group. Peer selection and peer socialization processes might explain why peer pressure serves as a risk factor for drug-abuse among adolescents [ 67 ]. Another study reported that strong religious beliefs integrated into society play a crucial role in preventing adolescents from engaging in drug abuse [ 46 ]. Most religions devalue any actions that can cause harmful health effects, such as substance abuse [ 68 ]. Hence, spiritual beliefs may help protect adolescents. This theme has been well established in many studies [ 60 , 69 , 70 , 71 , 72 ] and, therefore, could be implemented by religious societies as part of interventions to curb the issue of adolescent drug abuse. The connection with school and structured activity did reduce the risk as a study in USA found exposure to media anti-drug messages had an indirect negative effect on substances abuse through school-related activity and social activity [ 73 ]. The school activity should highlight on the importance of developmental perspective when designing and offering school-based prevention programs [75].

Limitations

We adopted a review approach that synthesized existing evidence on the risk and protective factors of adolescents engaging in drug abuse. Although this systematic review builds on the conclusion of a rigorous review of studies in different settings, there are some potential limitations to this work. We may have missed some other important factors, as we only included English articles, and article extraction was only done from the three search engines mentioned. Nonetheless, this review focused on worldwide drug abuse studies, rather than the broader context of substance abuse including alcohol and cigarettes, thereby making this paper more focused.

Conclusions

This review has addressed some recent knowledge related to the individual, familial, and community risk and preventive factors for adolescent drug use. We suggest that more attention should be given to individual factors since most findings were discussed in relation to such factors. With the increasing trend of drug abuse, it will be critical to focus research specifically on this area. Localized studies, especially those related to demographic factors, may be more effective in generating results that are specific to particular areas and thus may be more useful in generating and assessing local control and prevention efforts. Interventions using different theory-based psychotherapies and a recognition of the unique developmental milestones specific to adolescents are among examples that can be used. Relevant holistic approaches should be strengthened not only by relevant government agencies but also by the private sector and non-governmental organizations by promoting protective factors while reducing risk factors in programs involving adolescents from primary school up to adulthood to prevent and control drug abuse. Finally, legal legislation and enforcement against drug abuse should be engaged with regularly as part of our commitment to combat this public health burden.

Data availability and materials

All data generated or analysed during this study are included in this published article.

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The authors acknowledge The Ministry of Higher Education Malaysia and The Universiti Kebangsaan Malaysia, (UKM) for funding this study under the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). We also thank the team for their commitment and tireless efforts in ensuring that manuscript was well executed.

Financial support for this study was obtained from the Ministry of Higher Education, Malaysia through the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Nawi, A.M., Ismail, R., Ibrahim, F. et al. Risk and protective factors of drug abuse among adolescents: a systematic review. BMC Public Health 21 , 2088 (2021). https://doi.org/10.1186/s12889-021-11906-2

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Prevention of Substance Use among the Youth: A Public Health Priority

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• David Sidney Mangwegape 3 ,
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Excessive substance consumption is a growing public health concern globally as it alters the optimal function of the human brain, leading to severe physiological, psychological, and social problems. Compelling evidence shows that certain groups of people may be more vulnerable to substance use and misuse than members of the general population. These groups, sometimes referred to as “special populations” have unique health concerns that require exceptional attention in the prevention of substance use/misuse. Special populations include among others the poor or homeless, women, young adults or teenagers, the elderly, and trauma survivors. The focus of this chapter is on the prevention of substance use and misuse in young people and teenagers, including those that are homeless. Young people engage in substance use due to peer pressure or as a way of experimentation and, therefore, are more vulnerable. Several factors linked to substance use disorders among teenagers are also discussed. The chapter also utilises both primary and secondary data focusing on substance-related disorders in adolescents, enhancing resilience and methods for reducing risk behaviour. Challenges as well as best practices and recommendations for addressing stigma, treatment needs, the support structures needed for effective prevention of substance use in young people are also discussed.

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Manyanda, K., Mangwegape, D.S., Dambe, W., Hendrick, K. (2021). Prevention of Substance Use among the Youth: A Public Health Priority. In: Mhaka-Mutepfa, M. (eds) Substance Use and Misuse in sub-Saharan Africa. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-85732-5_10

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ORIGINAL RESEARCH article

The prevalence and determinant factors of substance use among the youth in ethiopia: a multilevel analysis of ethiopian demographic and health survey.

• 1 Department of Psychiatry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
• 2 Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
• 3 Department of Pediatrics, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
• 4 Department of Emergency Medicine and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
• 5 Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Background: In Ethiopia, the youth are more exposed to substances such as alcohol, Khat, and tobacco than other populations. Despite the seriousness of the situation, low- and middle-income nations, particularly Ethiopia, have intervention gaps. Service providers must be made more aware of relevant evidence to combat these problems. This research focused on finding out how common substance abuse is among teenagers and the factors that influence it.

Methods: The 2016 Ethiopian Demographic and Health Survey data were used for secondary data analysis. This survey includes all young people aged 15 to 24 years. The total sample size was 10,594 people. Due to the hierarchical nature of the survey data, a multilevel logistic regression model was employed to uncover the individual- and community-level characteristics related to substances.

Results: In Ethiopia, the overall current prevalence of occasional or daily substance use 30 days prior to the survey was 46.74%. Of the participants, 36.34, 12.56, and 0.95% were drinking alcohol, chewing Khat, and smoking cigarettes/any tobacco products, respectively. Male sex, 20–24 years of age, exposure to media, having a job, and living in large central and metropolitan regions were the factors associated with the problem.

Conclusion: According to the 2016 EDHS, substance use among young people is widespread in Ethiopia. To lower the prevalence of substance use among youth, policymakers must increase the implementation of official rules, such as restricting alcohol, Khat, and tobacco product marketing to minors, prohibiting smoking in public places, and banning mass-media alcohol advertising. Specific interventions targeting at-risk populations, such as youth, are mainly required in prominent central and metropolitan locations.

Introduction

Substance abuse has become a significant public health issue due to its widespread prevalence across all socioeconomic groups. It has a broad detrimental influence on socioeconomic development and severely endangers public health ( 1 – 3 ). According to a worldwide addiction report in 2017, 1 in 20 to 1 in 5 people aged 15 years and above highly use alcohol, tobacco, and illicit drugs daily ( 4 ). Youth includes late adolescents and young adults aged 15 to 24 years ( 5 , 6 ) who experience substantial changes in numerous facets of life throughout their youthhood, such as rapid physical growth and cognitive, moral, and emotional developments ( 7 , 8 ). If not properly managed, the youth are prone to risk-taking behaviors, including substance use ( 9 , 10 ). In the general population, late adolescence and youth are the vital phases at which substance use starts and reaches a peak ( 11 , 12 ). Alcohol, cigarettes, and cannabis have remained the most regularly consumed substances among youngsters worldwide ( 13 , 14 ). In Ethiopia, adolescents are particularly vulnerable to substances such as alcohol, Khat, and tobacco products ( 15 – 17 ). While alcohol is the most commonly used and abused substance, tobacco has the highest fatality rate ( 4 ). Shisha is another psychoactive substance commonly used in Shashemene town of southern Ethiopia. Shisha is smoking heated, specially prepared tobacco through a pipe. Shisha is also called a water pipe or a Hubble bubble. Like cigarettes, shisha can contain nicotine psychoactive ingredients.

As a result of increased sexual activity, youth who abuse substances are at a higher risk of unintentional injury and death (e.g., automobile accidents and suicide), overdose, and sexually transmitted infections ( 18 – 20 ). The influence of substances alters the mental state of people, increasing the chances of driving accidents and sexually transmitted diseases. Alcoholism and car accidents are well-studied risk factors for injuries and deaths, and substance-induced driving impairment is of increasing concern in many countries around the globe ( 21 ). Approximately 54% of sexually transmitted diseases and their associated consequences on Ethiopian patients with HIV/AIDS have been shown to be related to substance use ( 22 ). Long-term use increases the risk of several medical illnesses, such as lung disease, heart disease, liver disease, cancer, and psychological issues, such as anxiety, depression, bipolar and psychotic disorders, suicide, and violence ( 19 , 23 , 24 ). Substance abuse has a substantial financial impact due to lost production, deaths, and healthcare costs ( 13 ). Furthermore, substance addiction exposes individuals to polysubstance abuse and negatively impacts their quality of life in various ways, including their physical, psychological, social, and environmental activities ( 25 – 27 ).

According to different literature, the prevalence of substance abuse among adolescents varies depending on the substance. For example, people who use substances such as alcohol, Khat, and tobacco ranged from 11.3 to 60%, 9.7 to 74%, and 2 to 56.5%, respectively ( 16 , 17 , 28 ). The combined prevalence of regular or occasional alcohol consumption among youth in eastern Africa was 52 and 15%, respectively ( 29 ). In Ethiopia, a systematic review found that youth had a much greater rate of substance use, including alcohol, Khat, and cigarette products, than the general population ( 19 ). Another study among high school and university students found that 52.5% have used some substance at some point in their lives, with alcohol accounting for 46.2%, Khat for 24.7%, and smoking cigarettes for 14.7% ( 30 ). This demonstrates a disparity across several geographical contexts and time eras. Furthermore, a recent study of university students in Ethiopia found that drinking alcohol, smoking tobacco products, and chewing Khat was attributed to 26.65, 6.83, and 13.13% of youth, respectively ( 31 ).

Although substance abuse is a frequent problem among young people, evidence suggests that various factors contribute to its prevalence. Young adults (18–24 years), male sex, living in a divorced/separated family, urban location, unemployment, drug availability, and being out of school are some of the characteristics that increase the chances of substance use among those population groups in low- and middle-income nations ( 32 – 35 ). The sociodemographic factors linked with high substance use are also marital status, religion, higher educational achievement (college and university education), and high income ( 36 – 38 ). Other risk factors for juvenile substance use were peer pressure, having a family member who uses substances, and residing in large cities and regions ( 16 , 32 , 34 , 35 , 39 ). People also use substances for a variety of reasons, including pleasure, coping with life's challenges, stress and depression relief, staying alert while reading, and improving performance, a lack of alternative forms of recreation in their living environment, high income, and academic dissatisfaction ( 16 , 28 , 40 ). In addition, substance advertising and promotion using mass media are other important factors that engage youth to initiate substance use ( 41 ).

Previous literature has focused on substance use among youth attending different educational levels (high school, preparatory school, and college/university students). It lacks focus on community-based education using the national-level population dataset. According to the 2018 WHO Global Alcohol Status Report, Ethiopia does not have a coherent written national policy or action plan on alcohol control ( 42 ). Later in 2019, the General of the Ethiopian Food and Drug Authority approved the proclamations to reduce alcohol consumption ( 43 ). These include legislation prohibiting the promotion of alcohol on broadcast media and banning smoking in all indoor businesses, public areas, and public transit. The measure also establishes an age limit for alcohol consumption, making it illegal to sell any alcoholic beverage to anybody under 21 years. The Ethiopian government banned the marketing and chewing of Khat to minors in August 2019, comparable to other drugs, to combat Khat addiction ( 44 ). Ethiopia's parliament has also passed one of Africa's most burdensome anti-tobacco legislation to address substance abuse's health, social, and economic consequences ( 41 , 45 ). Even if the laws have been established, the prohibition of alcohol and other substances lacks in preventing harmful consumption among those aged 15 to 24 years. The current study is different from the previous review and single studies assessing the prevalence of substance use among the youth population group at the community level.

This study was based on the 2016 EDHS data that includes the entire nation with a large representative sample size. In addition, this study employed a multilevel logistic model to accommodate the hierarchical nature of the EDHS data. The result of this study will be used to deliver vital health information, which is crucial for policymakers to evaluate programs, design interventions, and strengthen the application of existing policies to reduce the risky consumption of substances among individuals aged 15–24 years. Therefore, this study aimed to assess the prevalence and identify the individual- and community-level determinants of substance use among youth in Ethiopia through a multilevel analysis.

• Is substance use high among Ethiopian youth (aged 15–24 years)?

• Are the individual- and community-level factors the determinant factors of substance use in the youth?

Materials and methods

Study setting, participants, and procedures.

The study was conducted in Ethiopia. Ethiopia is classified into nine regional states, two administrative cities, 611 Woredas (districts), and 15,000 Kebeles. Administratively, each region is divided into zones and zones into Woredas, which is the third administrative division of Ethiopia. Finally, the fourth level, Woredas, is further subdivided into Kebele, the lowest administrative unit. In 2020, Ethiopia's population is estimated to be 114,963,588 people according to UN data ( 2 ). The youth aged 15–24 years occupied 19.47% of the total population. Of them, nearly half of the youth are female. The study population was the youth aged 15 to 24 years, who show dramatic changes in multiple aspects of their life.

The data was extracted from the 2016 EDHS data collected between 18 January 2016 and 27 June 2016. The survey collects information on the demographic and health indicators of all household members, with particular emphasis on maternal and child health issues. The Ethiopian Population and Housing Census conducted by the Central Statistical Agency in 2007 was used as a sampling frame. A complete list of 84,915 Enumeration Areas (EAs) was used as a sampling frame to select the EAs for EDHS 2016, and each EA comprised 181 households. A two-stage stratified cluster sampling technique was used to conduct the survey. The regions were stratified into urban and rural, producing 21 strata. In each stratum, sample EAs were selected independently in two stages using proportional allocation and implicit stratification. Based on the 2007 Population and Housing Census, 645 EAs (202 in urban areas and 443 in rural areas) were selected in the first stage. In the second selection stage, 28 households per cluster were chosen with an equal probability of systematic selection supported by the newly created household listing.

Further detailed information about the sampling procedures and household selection is provided in the 2016 EDHS report ( 46 ). In this study, the individual characteristics of the respondents aged 15–24 years listed in the 2016 EDHS were used. A sample size of 10,594 youth was used for the final analysis from 645 EAs.

Study variables

The outcome variable of this study was self-reported. In the EDHS, questions were asked about substance use. The participants were asked four questions about whether they currently smoke cigarettes, pipes, or any other tobacco products, which were to be answered with a “yes” or “no.” The youth were classified as “cigarettes or tobacco smokers” if the response was “yes.” Again, two questions regarding alcohol drinking and Khat chewing were asked—“during the last 30 days preceding the survey, how many days the participants have a drink that contains alcohol, and how many days the participants have chew Khat, respectively?” Based on these questions, the youth were classified as “people who drink alcohol” and “people who chew Khat” if the response was “one or more days” (including occasionally or daily). Those who have no history of using those substances were considered “non-users.” There are also questions to be answered by “yes” or “no” about whether currently they use marijuana and shisha or nothing. However, there are no such cases reported in the survey. Shisha is a psychoactive substance that contains nicotine and psychoactive ingredients like cigarettes.

As a result, we have not included marijuana and shisha use in the analysis. Finally, for the simplicity of analysis, substance use was considered using specified substances such as alcohol, Khat, and cigarette/tobacco smoking, giving a sum-total score ranging from zero to three. Then, the sum score of the specified substances was categorized as “yes” if the total score was greater than zero and “no” if the sum score was zero. Therefore, in this study, substance use constitutes occasional or daily use of at least one of the specified substances such as alcohol, Khat, and/or tobacco within 30 days preceding the survey. The DHS contains no information about the standard amount of use of the products and duration of service in a session. Therefore, it was difficult to estimate the binge users.

According to the WHO, youth in the present study denotes late adolescents and young adults aged between 15 and 24 years ( 47 ). The individual- and community-level variables were considered independent variables in the study. Sex, age, marital status, educational achievement, household wealth index, individual media exposure, occupation status, and religion were the individual-level factors. Some of these factors were recategorized for the simplicity of analysis. Peer pressure, the presence of a family member who uses substances, and other reasons for using substances were not examined in this study and, therefore, were not included in the analysis. Place of residence, region, and community-level media exposure were considered community-level factors. In the EDHS, participants' media exposure was ascertained by three survey questions to be answered “not at all,” “at least once a week,” and “more than once a week” for the questions “how often do you have read newspaper or magazine; how often do you have listening radio, and how often do you have watching television?” Based on these questions, the individual level of media exposure was obtained by aggregating the specified ways of getting information, such as reading news or magazine, listening to the radio, and watching television which gives a sum-total score ranging from zero to six. Then, the total score of media exposure was categorized as “yes” if the total score was greater than zero and “no” if the sum score was zero. Therefore, in this study, an individual's media exposure was defined as those who have a chance to get information through at least one of the three specified mass media such as reading news or magazines, listening to the radio, and/or watching television at least once per a week.

The community-level media exposure was obtained by aggregating the individual-level media exposure into groups using those who had media exposure. This community-level media exposure shows the general media exposure within the community. Since the aggregated variable had a skewed distribution, the median values were categorized as higher and lower. This study region was recategorized into three categories; larger central [Tigray, Amhara, Oromia, and Southern Nations Nationalities and People's Region], small peripherals [Afar, Somali, Benishangul, and Gambela], and metropolis [Harari, Dire Dawa, and Addis Ababa] supported by their geopolitical features, according to previous studies from Ethiopia ( 48 , 49 ).

Data management and statistical analysis

The extracted EDHS data included the youth respondents' sociodemographic and behavioral characteristics. The cleaned and recoded data were analyzed using STATA version 14. Descriptive statistics such as frequencies and percentages of variables were presented using texts and tables. Sample weights were performed throughout the analysis to restore the representativeness and to adjust the nonproportional allocation of the sample to enumeration areas (clusters) and regions during the survey process. A mixed multilevel logistic regression analysis was employed to account for the hierarchal nature of the EDHS data. First, a bivariable multilevel logistic regression analysis was performed, and those variables with a p -value of < 0.20 were selected for multivariable analysis. In the multivariable analysis, variables with a p -value of < 0.05 were considered statistically significant, and the factors associated with substance use were reported by an adjusted odds ratio (AOR) at a 95% confidence interval.

After selecting variables for multivariable analysis, four models; the null model (without explanatory variables), model II (containing only individual-level factors), model III (examined the effect of community-level factors), and model IV (which constitutes both individual and community-level factors) were fitted. Model comparison and fitness were assessed using the deviance and Akaike information criterion (AIC), and the model with lower deviance and AIC (Model IV) was selected as the best-fitted model. However, it can be hard to interpret the AOR in multilevel logistic regression since the community-level variables are constant for all individuals in the clusters. A better way of interpreting the AOR is by contrasting two clusters differing in the value of the contextual variable by one unit. In the final model (model IV), we have used the 80% interval odds ratio (IOR-80%) to address this limitation in interpreting the effects of community-level variables. It quantified the AOR using the community variance. The IOR-80% is defined as the middle 80% range of the distribution of OR formed by making the random pairwise comparison between the clusters exposed and nonexposed to the contextual variable. The IOR-80% interval is narrow if the variation of substance use between clusters δ u 2 is small and is comprehensive if the substance use variation between clusters is considerable. For some clusters, the association is opposite to the AOR if the IOR-80% interval is 1 ( 50 , 51 ).

In addition, the measures of community variation (random effects), which are the measures of variation of substance use across communities or clusters, were estimated by the intra-class correlation (ICC), median odds ratio (MOR), and proportional change in variance (PCV) ( 51 – 53 ). These ICC, MOR, and PCV values were calculated to quantify the degree of homogeneity of substance use within clusters, the degree of variation of substance use across clusters in terms of the odds ratio scale, and the proportion of variance explained by consecutive models, respectively.

Descriptive statistics of the youth characteristics

Weighted samples of 10,594 youth aged 15 to 24 years were included in this data analysis. More than half of the participants (57.98%) were female and 43.86% were Orthodox Christians. Nearly two-thirds of the participants were never married, 57.35% of them had attended primary school, and 59.78% of the participants were employed or had private work. The prevalence of alcohol drinking was higher among the youth living in the Amhara region (77.73%) and Khat chewing was more prevalent among individuals living in rural areas (13.99%) than those living in urban areas. Moreover, drinking alcohol, chewing Khat, and smoking were more prevalent among the youth aged 20 to 24 years than those aged 15 to 19 years. Higher proportions of individuals with lower monthly income were Khat chewers, but alcohol use was higher among individuals with higher monthly income ( Table 1 ).

Table 1 . Descriptive statistics of substance use by the youth according to the 2016 EDHS data (weighted data = 10,594).

The prevalence of substance use

In 2016, 46.74%, with a 95% CI of 45.88 to 47.78, of Ethiopian youth aged 15 to 24 years (56.26% male subjects and 40% female subjects) reported consuming at least one specified substance (alcohol, Khat, or cigarette/ tobacco products). Of the participants, 36.34% ( n = 3,850), 12.56% ( n = 1,331), and 0.95% (101) were drinking alcohol, chewing Khat, and smoking any tobacco products, respectively. Of those who reported using these specified substances, 45.2% of male subjects and 31.09% of female subjects reported drinking alcohol and 18.05% and 1.69% of male subjects were chewing Khat and smoking any tobacco products, respectively ( Table 2 ).

Table 2 . The prevalence of substance use in Ethiopia, 2016 (weighted data).

Random effects and model fitness

In the null model (model I), there was a significant variation in the log odds of people who use substances across the communities (σ2 u0 = 3.36, P < 0.001, and 95%CI: 2.85–3.96). This variation remained significant after controlling all models' individual- and community-level factors. As shown by the estimated ICC coefficient, about 50.53% of the total variation of the people who use substances could be attributed to the cluster-level effects (unexplained variation). The null model also had the highest MOR value (5.71), indicating that when randomly selecting an individual from one cluster with a higher risk of substance use and the other cluster at lower risk, individuals in the cluster with a higher risk of substance use had 5.71 times higher odds of having used at least one substance (alcohol, Khat, or smoking/any tobacco products) as compared to their counterparts. In addition, the highest PCV (48.8%) in the full model (model IV) indicates that the log odds of having substance use variation across the community level, and the 48.8% of the variation was explained by the combined factors at both the individual and community levels ( Table 3 ).

Table 3 . Model comparison and goodness-of-fit test in the multilevel analysis.

The model fitness was ascertained using the log-likelihood, deviance, and AIC values as indicated in Table 3 , in which lower values were observed in the full model (model IV). This indicates that model IV for youth substance use was a better explanatory model. This also suggests that the addition of the community compositional factors increased the ability of the multilevel model, indicating the goodness-of-fit of the multilevel model.

Factors associated with substance use

The bi-variable multilevel modeling showed that sex, age, marital status, educational attainment, household wealth index, occupational status, individual's media exposure, living residence, living region, and community-level media exposure have a p -value of < 0.2. A multivariable multilevel logistic regression analysis, where the individual- and community-level factors were fitted simultaneously, indicated that male sex, 20–24 years of age, having a job, exposure to media, and living in large central and metropolitan regions were significantly associated with substance use with a p -value of < 0.05.

The odds of substance use among the youth were 2.65 times [AOR = 2.65; 95% CI: 2.12, 3.30] higher in male subjects than female subjects. The odds of substance use were 57% [AOR = 1.57; 95%CI; 1.31, 1.88] higher in the youth in the age group of 20–24 years compared with the youth in the age group of 15–19 years. Regarding individual media exposure, youth who had exposure to media at the individual level had 1.49 times [AOR= 1.49; 95% CI: 1.17, 1.90] higher odds of substance use as compared to those who have not been exposed to mass media (reading news and/ magazine; listening radio, and/ watching television). The youth who had a job had 1.68 times [AOR = 1.68; 95% CI: 1.39, 2.03] higher odds of substance use as compared with the youth who have not worked. The 80% IOR value for the living region characteristics in model IV were (2.06, 239.13) and (1.29, 149.46) for large central regions vs. small peripheral regions and metropolitan regions vs. small peripheral regions, respectively. They were (0.22, 24.95) for urban residence vs. rural residence and (0.26, 30.18) for the presence of higher vs. lower community-level media exposure. Thus, when comparing the youth with identical characteristics, one selected from a large central region or a metropolitan region and one from a small peripheral region, the odds of substance use will lie between (2.06 and 239.13) or (1.29 and 149.46), respectively, in 80% of such comparisons ( Table 4 ).

Table 4 . Multivariable multilevel logistic regression results of both individual- and community-level factors associated with substance use in youth, EDHS 2016.

The youth is the most turbulent time in human development and is highly prone to multiple risk-taking behaviors. Alcohol, Khat, and tobacco are the common substances used by Ethiopian youth. This study attempted to assess the prevalence and determinant factors of substance use among youth in Ethiopia.

In this study, the prevalence of substance use among the youth in Ethiopia was 46.74%, with a 95% CI of 45.88–47.78. This finding was in line with the reports in sub-Saharan Africa (40–59.9%) ( 54 ) and Nigeria (46.3%) ( 55 ). Conversely, our finding showed a lower prevalence than that reported in other studies conducted in Ethiopia ( 30 ), Eastern Africa ( 29 ), Rwanda ( 56 ), South Africa ( 57 ), and Nigeria ( 58 ). On the other hand, the result of this study showed a higher prevalence than that reported in previous studies conducted in Rwanda ( 59 ) and Egypt ( 60 ). The variation might be due to the study area and sample size differences as most of the indicated studies were institution-based with a small sample size in which lower rates of substance consumption are expected compared to this large population-based study. The discrepancies could also be due to the differences in the study population, study design, and interest to measure. For example, small geographical, institution-based, and standardized substance consumption identification questionnaires were used in most of these studies, while national-level population-based data and substance use behavior assessment DHS questions were used in this study. When data are collected from a single institution, a higher/lower rate of individuals may consume substances if there is higher/lower availability and use pattern of drugs in the community. A systematic review and meta-analysis study among in-school youth was used in an eastern African study whereas a cross-sectional study among individuals aged 15–24 years from the 2016 EDHS data was used in this study. In addition, the interest of study was on fewer substances in a Nigerian study among university students. Instead, we have included alcohol, Khat, and tobacco products which are commonly used in Ethiopia. Therefore, variations in the magnitude of multiple substances vs. fewer substances are expected. Besides, the discrepancies between the finding of this study and that of the findings of studies conducted in Ethiopia might be due to sociodemographic and cultural differences. This is due to the fact that consuming substances like alcohol, Khat, and tobacco products differ across countries and subpopulations.

One unexpected finding in this study is that no one from the sample population has admitted to the recent use of cannabis and shisha. This finding is different from previous studies in which there was a high prevalence of cannabis and shisha use in the Ethiopian community ( 61 , 62 ). The possible reason might be that previous studies were conducted in a specific area where the products are produced and available in the community. Cannabis is frequently consumed in Shashemane town, southern Ethiopia where the previous studies were conducted. Most of the factors associated with substance use in this study were different from those reported in previous studies in Ethiopia. For example, living in large central and metropolitan regions, individuals' media exposure and having work (job) were not addressed and associated in the other studies. In this study, we observed that male youth were more likely to use substances compared to female youth. This report is consistent with those of other studies ( 63 – 65 ), which showed that male youth commonly use substances. The possible justification for male youth having higher odds of substance use was undesirable masculine traits, like drinking, chewing, or smoking to reduce distress and a tendency to bypass social sanctions ( 66 ). The other explanation for the gender difference might be substances like alcohol, Khat, and tobacco are commonly practiced and socially regarded as a male habit in Ethiopian culture.

The age of the youth is an important contributor to substance use in which the odds of substance use were higher among older youth aged 20–24 years compared to younger youth aged 15–19 years. This finding was in agreement with other studies done in Ethiopia ( 63 , 65 ), Rwanda ( 59 ), and Nigeria ( 58 ). This could be due to the fact that the use of substances among youth almost always increases as their age increases ( 67 ). Furthermore, the younger population has a higher rate of substance use, with adolescence being the critical period for initiation and the young age (18–25 years) being the peak age for substance use ( 11 , 12 ). This study revealed that the odds of substance use were higher among the youth who had a job compared to those who have not worked. This higher proportion may likely be related to the adequate income needed to buy the substances. The higher the income, the higher the chances of abusing drugs by the youth. As observed from the result, most Khat chewers are individuals with lower monthly incomes as Khat can be easily cultivated on their agricultural land and is cheaper to buy. At the same time, alcoholism was higher among individuals with higher monthly incomes as more money is required to buy alcohol than that is needed to buy Khat.

In this study, the youth who had media exposure (reading newsletters/magazines, listening to the radio, and/or watching television) at the individual level were more likely to consume substances than those who have no media exposure. This finding is in agreement with another study ( 35 ). This could be because the youth populations are vulnerable to substance use, which is encouraged by the deception and manipulation strategy of substance advertising and marketing ( 41 ). This implies that banning drug advertisements using mass media, controlling alcohol, Khat, and tobacco product marketing for under ages, and expanding substance use–related education using mass media are essential to intervene in youth before and after starting substance use.

Furthermore, this study region is also associated with youth substance use. The youth from large central and metropolitan regions were more likely to have substance use as compared to small peripherals. This is consistent with a study done in Rwanda ( 56 ), India ( 68 ), and England ( 69 ), which showed that regional variation is a consistent predictor of substance use. This might be due to the easy availability and access to big commercial trade with one another and higher challenges of life due to lower social relationships in urban areas like metropolitan regions ( 70 ). In addition, large central regions are more agrarian regions where the survivors have produced local alcoholic beverages, such as “Tella,” “Areki,” and “Tej” in the rural areas and “beer” and “wine” in the urban areas, from agricultural products than in the small peripherals ( 71 ).

One of the main limitations of this study was that the DHS did not have information about the standard amount of use of substances and duration of use in a session which limited us from identifying the binge use of the products in the survey. Second, underreporting of substance-use behavior is common because of social desirability bias as consuming substances may be perceived as socially and culturally undesirable, making it difficult to determine the accurate magnitude of substance use through the survey. Due to logistical reasons, the researchers might have experienced difficulties in reaching locals. Therefore, to overcome such difficulties, they might have collected data from participants who could be reached easily. This sampling bias could influence the representativeness of the findings. Another limitation of this work might be the recall bias because the data collection took place 6 years before the survey of the study. Besides, the research could not show the cause–effect relationships between factors and outcomes owing to its cross-sectional nature.

The prevalence of using at least one substance in the youth in Ethiopia was high. Male sex, 20–24 years of age, exposure to media, having a work/job, and living in large central and metropolitan regions were the factors associated with the problem. It is crucial that the policymakers strengthen the application of the existing policies, especially controlling alcohol, Khat, and tobacco product marketing for minors, smoking in public places, and banning broadcasting alcohol advertisements for reducing the prevalence and consequences of substance use among individuals aged 15–24 years. As expressed in the introduction, the cost and excise tax of the products in our country are lower compared to other countries. Therefore, increasing the retail cost and excise tax of alcohol and tobacco products might help in reducing the number of users and the risky consumption of substances. Yet again, special interventions targeting risky youth such as those living in large central and metropolitan areas are also needed to intervene in substance use at an early age.

Data availability statement

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.

Ethics statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

TK and BT developed the proposal, requested the data from DHS, extracted, recoded, analyzed the data, and wrote the draft manuscript. GT assisted in proposal development, data analysis, and manuscript writing. TA extracted, cleaned, and recoded the data and checked the data analysis. SK revised the proposal and assisted with manuscript writing. BL revised the proposal and revised and approved the manuscript. Finally, all authors have read and approved the manuscript.

Acknowledgments

The authors are very grateful to the MEASURE DHS International Program that provided them with the necessary dataset used for the study.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: alcohol use, psychoactive substances use, substance use, youth, Ethiopia

Citation: Kassew T, Tarekegn GE, Alamneh TS, Kassa SF, Liyew B and Terefe B (2023) The prevalence and determinant factors of substance use among the youth in Ethiopia: A multilevel analysis of Ethiopian Demographic and Health Survey. Front. Psychiatry 14:1096863. doi: 10.3389/fpsyt.2023.1096863

Received: 12 November 2022; Accepted: 24 February 2023; Published: 23 March 2023.

Reviewed by:

Copyright © 2023 Kassew, Tarekegn, Alamneh, Kassa, Liyew and Terefe. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Tilahun Kassew, tilahunkassew123@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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A Qualitative Analysis of Substance Use among Liberian Youth: Understanding Behaviors, Consequences, and Protective Factors Involving School Youth and the School Milieu

Samuel j pullen.

1 St. Luke’s Health System Department of Psychiatry and Behavioral Health, Boise ID, USA

Liana Petruzzi

2 Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

3 University of Texas at Austin School of Social Work, Austin, TX, USA

Brittany CL Lange

4 Yale School of Public Health, New Haven, CT, USA

Lindsey Parnarouskis

Silvia dominguez.

5 Harvard Medical School, Boston MA, USA

Benjamin Harris

6 AM Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia

Nicole Quiterio

7 Bay Area Children's Association, Oakland, CA, USA

Michelle P Durham

8 Boston University School of Medicine, Department of Psychiatry, Boston Medical Center, Boston, MA, USA

Gondah Lekpeh

Burgess manobah, siede p slopadoe.

9 Christ Jubilee International Ministries, Lowell, MA, USA

Veronique C Diandy

Arthur j payne, david c henderson, christina pc borba.

Substance use is a significant and common problem among school-aged youths throughout Africa. Like other countries on this continent, the West-African nation of Liberia is recovering from civil war. A well-educated population of young people is critical to the recovery efforts and long-term success of Liberia. Substance use by school-aged youths has important public health consequences that could undermine Liberia’s post-conflict recovery efforts. We wanted to better understand the culturally significant themes and subthemes related to substance use among youths attending public schools in Monrovia, Liberia.

A qualitative research design was used to collect data from 72 students attending public school in Monrovia, Liberia. Nine focus groups of 6–8 students from three public schools were facilitated using a semi-structured format to guide discussions on substance use. Student narratives were translated and re-occurring themes and subthemes were coded and analyzed.

Four emergent themes described in this study were:

Behaviors associated with substance use

• Consequences associated with individual use
• Consequences of substance use that affected the school milieu
• School-related factors that were protective from substance use.

Subthemes associated with substance use included concealment of substances, intoxication and disruption of the classroom environment, expulsion from school, school drop-out, and school as protective against substance use.

Liberian school-aged youths described important themes and subthemes associated with substance use occurring within the school milieu. These data have germane public health ramifications, and could help inform larger epidemiologic study methods and public health interventions for Liberia and countries with similar profiles.

Introduction

In 2003, the West-African nation of Liberia emerged from fourteen years of civil war, which ravaged the country’s economic, health, and education infrastructures [ 1 ]. Chronic diseases such as HIV/AIDS, mental illness, and substance use disorders continue to plague Liberia’s population, and hinder recovery efforts [ 1 , 2 ]. Economically, Liberia remains one of the poorest countries in the world. One strategy to reverse this statistic would be to improve the education and high unemployment rate of Liberia’s population, the majority of which are youths (comprising approximately 65% of Liberia’s population of 4.1 million persons) [ 3 , 4 ]. Such an intervention was cited by Liberia’s president as being critical to improving the country’s future peace and security, and preventing the country from lapsing back into civil war [ 4 ].

Youths in sub-Saharan African countries, such as Liberia, share an important bidirectional relationship with the socio-economic forces that impact post-conflict societies; including changes in political institutions, rapidly expanding global networks and the increasing importance placed on school and higher education in workforce and economic development [ 5 ]. This underscores the importance of establishing stable school environments and actively engaged youths who are motivated to pursue higher education in post-conflict societies [ 5 ]. Although some progress has been made in improving education rates among youths in sub-Saharan Africa more concerning trends towards high-risk behaviors such as alcohol and other substance use are also on the rise [ 5 ].

Substance use among youths is a significant problem globally. Substance use is associated with increased risk for a number of well-established consequences including impaired peer relationships, mental illness, increased risk for suicide, high-risk sexual behavior, HIV/AIDS, disrupted learning, truancy, increased school drop-out rates, and poverty [ 6 , 7 ]. Substance use among school students in many African countries is also common and has been associated with similar consequences [ 8 – 11 ].

Given the importance of school, and higher education in sowing the seeds of post-conflict recovery; substance use among youths in sub- Saharan countries, such as Liberia, is an important public health problem, and could undermine progress made in these fragile countries emerging from conflict [ 8 , 9 , 12 , 13 ]. Furthermore, Liberia is one of several sub-Saharan countries that have become even more fragile in the aftermath of the recent Ebola outbreak, which has put significant strain on the government and healthcare system [ 14 ].

Alcohol and substance use is thought to be highly prevalent among secondary school students in Monrovia, Liberia. In one pilot study using a cross-sectional survey of 802 Liberian school students, 51% of respondents reported using alcohol, and 9% of respondents reported using marijuana underscoring how prevalent alcohol and substance use is among secondary school students in Monrovia, Liberia [ 12 ]. However, less is known about the specific behaviors, consequences, or cultural idioms associated with substance use among youths attending school in Liberia [ 12 ]. Thus, we sought to better understand important themes and subthemes associated with substance use among youths attending public schools in Monrovia, Liberia.

Our research group used a qualitative research design to solicit information about substance use from public school students divided into small focus groups in Monrovia, Liberia. In this study we report on student responses specific to behaviors, consequences, and protective factors associated with substance use in the school setting. A better understanding of cultural idioms and themes from the student’s perspective could be helpful in laying the groundwork for larger epidemiologic studies, and help inform prevention strategies in Liberia and countries with similar profiles.

Study design

A semi-structured, qualitative research design was used to collect information from nine focus groups with 6–8 students per group. A total of 72 public school students were recruited using a convenience sampling design. Each school had an all-female focus group, an all-male focus group and a mixed-sex focus group. Students were recruited and focus group discussions were conducted using a ‘best practices’ approach similar to what is discussed by Plummer-D’ Amato [ 15 , 16 ]. Specifically, we defined the term ‘focus group’ to mean a specialized group interview facilitated by a moderator to obtain data on participant attitudes, beliefs, vocabulary, and thought patterns from a relatively homogenous target population [ 15 , 16 ].

Group size adhered to the recommended number of 6–8 participants to optimize participant interaction [ 15 ]. The number of groups, nine in this case, adhered to the principal of saturation – the point where no new information was likely to be obtained by adding additional groups [ 15 ]. We attempted to reduce moderator bias by using a moderator who was not previously known to the participants, and was more likely to be emotionally detached from the subject matter in question. Additionally, moderators used a triangular method, a technique that helps assure reliability and credibility of qualitative research designs by seeking the same information using different interview techniques within the course of the same interview, to structure the format of interview questions [ 15 ]. As an example, in a semi-structured interview, an interviewer might begin by asking the focus group an open-ended question about substance use in the school setting, and later in the course of the same interview might ask more specific probing questions about themes of substance use in the school setting [ 15 ]. Alignment of responses to questions asked in different ways helped to assure their validity.

Participants were recruited and enrolled in the study through the assistance of staff at these schools. Eligible participants could be male or female, were required to be enrolled in a public elementary, middle or high school in Monrovia, and were required to be able to provide written informed consent.

Data collection

Data was collected from focus groups on April 10, 2012 through April 12, 2012. Ethical approval for this study was obtained from the University of Liberia Institutional Review Board and the Partners Healthcare Institutional Review Board. Written informed consent was obtained from all study participants. If a participant was under the age of 18, child assent was obtained along with parental/guardian consent. Participants were given copies of the consent form to bring home and discuss with their parent or guardian. Participants were explicitly given the right to refuse participation or to stop participation at any time. Participants were compensated with a $5 phone card for their time. Confidentiality was maintained through the use of study IDs for each participant and all identifying information was removed prior to transcription. Access to study data was restricted to the investigator and the research team. All electronic versions of the documents required password protection and storage on a secure network.

All discussions were held using the preferred language of the students, and if they were non-English speaking, a Liberian medical school student translator was made available. An expert in qualitative interviewing and coding trained all study staff. Focus groups were recorded and notes were taken by both the primary interviewer and the Liberian medical school student translator during and after the focus groups to ensure accuracy. In the event of a mental health or medical crisis a local psychiatrist and medical provider was made available to contact.

Study measures

Students were initially asked open-ended questions inquiring about substance use. Interview questions were constructed using a literature search to inform the content and structure of the questions. The sole Liberian psychiatrist in the country was then asked to edit and adapt the questions to be relevant for study participants. Examples of questions included “I’m wondering if you know anyone or have met anyone that has used drugs such as alcohol or substances?” “Do parents have any influence on students smoking marijuana and drinking alcohol and coming to school?” Interviewers then used probing techniques in order to capture supplemental information regarding the participants’ responses to the research questions and to further engage students to share their personal experiences. For example, as a follow up to a description of a boy who brought food mixed with marijuana to school the interviewer asked, “So this is a boy that actually was in school. So what happened to him as a consequence?” Focus groups were run for approximately 90 minutes, and were facilitated by an interviewer - a research fellow from the parent institution, and a Liberian medical school student translator.

Data analysis

After the transcription of focus groups, which were completed verbatim, five coders who had undergone formal training in qualitative research, independently read the focus groups and met to discuss initial perceptions of the transcripts. To preserve the fidelity of the coding process, at least two members from our research group were required to code the transcription narratives. Upon independently coding the first three focus groups, coders met to discuss and agree upon codes to create a preliminary codebook, which was used as a template to identify similar themes when coding subsequent transcription narratives. After completion of the initial codebook, coders independently coded one focus group at a time, and then met for a period of time lasting 45 minutes up to two hours on a weekly basis, for a total of 25 meetings to discuss and agree upon codes, and add new codes to the codebook as necessary. If there were any disagreements among coders, they were managed by discussing the differing perspectives as a group, and arriving at a majority group consensus. If the coders could not come to a consensus at the time of discussion, the transcript excerpt in question would be recorded on a memo, and saved for future discussion after additional transcript narratives were coded to determine if there were recurring themes necessitating a new code be created, or how the transcript excerpt in question would best fit with already established codes.

As coding proceeded, categories were clustered together, from broad topics such as “substance abuse,” to increasingly specific themes and subthemes, such as “alcohol use in a community setting”. A corresponding definition was also created for each code to ensure coding consistency. For each code added to the codebook, a consensus was reached between the coders to ensure inter-coder reliability. Thematic content analysis was conducted and data were coded based on reoccurring subject themes and patterns. NVivo software was used as a data management tool [ 17 ].

Descriptive data

Students were divided into a total of nine focus group units, three focus groups from each school, comprising 6–8 students per group ( Table 1 ). Data was collected from a total of 72 school students (37 male students and 35 female students), 24 students per school from a total of three public schools, ranging in age from 12–20 ( Table 1 ). Reoccurring themes and subthemes associated with behaviors, consequences of substance use, and protective factors among school-aged youths in public schools were identified in each of the focus group transcript narratives. We reported on specific subthemes related to each of the principle themes, and their relationship to substance use in the public school setting as discussed in the focus groups.

Demographics of Public School Student Participants in Focus Groups in Monrovia, Liberia.

Analyzed interview data

Important themes of substance use in the school setting were

(i) Behaviors associated with substance use; (ii) consequences that affected or were related to the individual(s) using the substance; (iii) consequences that affected the school milieu sometimes used interchangeably with the term ‘school classroom environment’, which included other students, teachers, and the general environment of the classroom and school; (iv) Factors which students described as protective from substance use.

A subtheme related to behaviors associated with substance use included concealment and bringing substances to school. Individually experienced consequences of substance use included subthemes of intoxication, misbehavior, confrontation with teachers or other authority figures, suspension, expulsion, and dropping out of school. Subthemes related to consequences affecting the school milieu included unknowingly ingesting a substance mixed with food or beverage, knowingly engaging in substance use which led to aggressive behaviors and caused disruption in the classroom, as well as interference with learning. Students also described aspects of school that they felt were protective. Students reported that school was a protective factor against substance use, early pregnancy, and was important for their future.

As described in the focus groups, the four themes of behaviors, individual consequences associated with substance use, school classroom environmental consequences associated with substance use, and protective factors of school were important in providing context for a working model of how these themes of substance use among school-aged youths were interrelated ( Figure 1 ).

A proposed model of how important themes associated with alcohol and substance use in public school are interrelated as discussed in focus group narratives at three public schools in Monrovia, Liberia.

Concealment and Bringing Substances to School: Behaviors associated with substance use affecting individuals at school seemed to begin with students bringing alcohol or substances to school by either concealing the substance in their school bags or hiding the alcohol or drugs in food and beverage items.

“Opium, cocaine, drinking liquor going to school.”

“Yes some of them they carried it in their bags like their school bags because of the time people don’t check in the bags.”

Parents, a potential and important source of influence on this behavior, were described as being unaware that this practice was occurring.

“The parents don’t know anything about it. Parents are usually gone to work.”

Substances were commonly hidden in food items such as kanyan - a popular Liberian food made of gari, sugar, and peanuts or beverage items such as juice, tea – called “direct”, or ‘Kool Aid’ sometimes identified by the cultural idiom “big mama”.

“Sometimes they mixed those grass (marijuana) with a food that we eat called kanyan.”

“Last year I had a friend who used alcohol all the time, even in class. It was red and they called it big mama. They sat back and would drink the alcohol in class. It was a group of them.”

Reasons for bringing substances to school varied. Alcohol and other substances were used as a means of coping with social anxiety and public speaking, and were also viewed as aiding one in becoming more ‘active’ and socially outgoing.

“According to him he is shy, so the only way that he can talk is unless he drinks alcohol.”

“Sometimes they just want to be active among their friends.”

Some students believed that using alcohol and substances before school would make them smarter.

“According to him he said that when he takes alcohol and he comes to school he canbe smart, but he stopped it.”

Still others used drugs and alcohol as a means of self-treating mental illness such as depression or post-traumatic stress disorder if they had previously been forced to serve as a “child solider” in past conflict as an example.

“Some people smoke and drink liquor to forget their problems. They’re frustrated so they do it to keep from committing suicide.”

Students also described youths intentionally becoming intoxicated, identified by the cultural term “weesie” (which referred to ‘getting high’) prior to coming to school so that they could be disruptive in class.

“As for me, I think its marijuana, most of our friends take in for self-desire to disturb.”

Individual consequences of substance use

Intoxication and misbehavior: Intoxication and associated misbehavior were two important subthemes that emerged from the data that affected individual students. Students who brought alcohol and/or other substances to school were described as exhibiting varying degrees of intoxication in the classroom setting or other school functions such as a school “gala” similar to a school assembly.

“Sometimes people come to school with liquor and drink on campus on gala day.”

Intoxication from substance use was associated with altered mental states, physical effects, and repeated substance use was associated with increased risk for addiction. Students also described their intoxicated peer as struggling with their own learning, whether or not that individual experienced other ‘disrupted learning’ consequences related to substance use such as being suspended or expelled from school. Nearly all of the focus groups associated intoxication with misbehavior.

“Because when you smoke and a teacher is teaching you don’t learn anything.”

Students described various physical consequences of recurrent substance use, and altered mental states of intoxicated classmates.

“It can damage your heart that it makes your intestine to damage like that. It can make your intestine rotten because every day you are out smoking on your lungs it can damage your lungs.”

“It (opium) makes you behave like someone who’s crazy, makes you stupid in the head…acting, yelling, and misbehaving.”

Students also described repeated intoxication as leading to longer-term deleterious physical and mental effects that also affected learning among individuals using alcohol and drugs regularly.

“And mainly if you continue drinking alcohol it makes your mind weak and you cannot study anymore, and you will sleep all day, disturb the class, act rude so it really affects the mind.”

Intoxication was also associated with misbehavior and subsequent disruption of the classroom environment.

“On such occasions they agree to get drunk. They drink and then come to class, disturb the class and talk back at the teacher.”

The link between substance use, intoxication, and misbehavior was described in nearly all of the focus groups.

In some cases, it seemed clear that some students intended to misbehave in the classroom and intoxication from substance use accentuated this behavior. In other cases, it was unclear whether substance use was used as a rationalization for misbehavior and perhaps to escape consequences, or if students used substances with the intention of acting out in the classroom. Some student narratives clearly described a sense of bravado when interacting with the teacher (‘give talk to the teacher’) or other authority figure.

“Some of them boast about it. They say they do drugs and get drunk before coming to school in order to be in ‘weesie’ (high) so that when the teacher talks they can ‘give talk to the teacher’.”

Misbehavior seemed to be directly associated with confrontations with the teacher, which led to additional individual consequences such as being suspended or expelled from school.

Confrontation with the teachers and expulsion from school: In many instances behavioral acting out seemed directed specifically toward the teacher.

“When the teacher tries to stop them, they will go and fight the teacher. The last time a teacher entered in class and a boy took the opium and drank the liquor. So when the instructor enters the class, he started misbehaving.”

According to students from these focus groups, confrontation with teachers led to the individual consequence of suspension or expulsion from school.

“In our class, there was a boy who was very rude. He said if he doesn’t smoke, he couldn’t control his behavior. Even the teachers couldn’t control his behavior. He was given NTR (never-to-return/ expulsion).”

Students stated that many of their disruptive peers who were expelled from public school were simply transferred to different schools. If their parents were affluent, those individuals expelled from school would be transferred to “big” schools or private schools.

“They give them extra assignments, suspend or expel them. Most of their parents have money so they can afford to pay money to go to another school.”

Students described a more permissive culture in private school classrooms where students more openly used substances and teachers could be bribed. Some students who continued to use substances chronically would go on to develop features of addiction using the cultural idiom, “it becomes a part of you”.

“Most of them attend private schools. They come there and smoke and drink.”

“Some students now, going to the big, big schools they go they smoke enough; sometimes teachers can see them, but they can give the teachers money, the teachers can’t talk it. So they can just leave them alone, and when it grows inside of you, it just is part of you. Even you finish high school it will just be part of you, you will not do anything for yourself.”

Other students who were expelled from school were described as “street people” who were of lower socioeconomic class, and were described as living out in the streets, the community, or near venues where one could acquire drugs, identified by the cultural term “ghetto”.

“The first thing is that they are not will to learn because they are street people. They stay in the streets all night and in the morning they come to class to embarrass the rest that are will to learn.”

Students of lower socioeconomic background who were suspended from school returned to class after a period of time, although there was no indication that suspension from school resulted in changing an individual’s behavior; whereas poorer students who were expelled from public school returned to their community, as their parents were not able to afford private schooling.

“And then they can give them suspension two months and after one day, people will see back in the class.”

Expulsion from school served to remove a disruptive individual from the classroom environment thus leading to a potentially positive outcome for other students in the classroom. However, data from these focus groups underscored apparent differences in socioeconomic status among students in public schools leading to differing outcomes for students who were expelled from school, and the perception that expulsion from school was not an effective deterrent to using substances

“Yes sometimes they can expel them or they make them to work like clean up the campus, scrub bathroom, cut grass, but that don’t stop them because they can still go on and doing the same things.”.

Additionally, expulsion from school halted an individual’s education, particularly poorer students, limited opportunities to learn about other critical topics such as STD’s and safe sex practices, and increased the likelihood that school-aged youths would be more prone to engage in criminal behaviors such as stealing and sexual violence. School-aged youths who were no longer attending school were at increased risk for committing acts of violence connected with substance use including theft, and sexual violence, which was described in many of the focus groups.

“They will be stealing just to go buy drug or just to buy alcohol.”

“Sometimes when boys smoke, they take people’s children to their rooms and rape them. They end up infecting children with all kinds of sickness.”

Dropping out of school: Substance use was also associated with dropping out of school.

“Because many at times some of our friends their parent can pay their school fees but at the end of the day because of the smoking (marijuana), they will not end the year and they will drop from school.”

The subtheme of dropping out of school was separated from being suspended or expelled from school as the latter consequence was not considered to be a direct choice of the students, but was more directly connected to the consequence of misbehavior in school related to intoxication/substance use, whereas dropping out of school seemed to be a choice of students or a consequence of previous choices made by a student (i.e. recurrent substance use leading to addiction, unplanned pregnancy, etc.).

“Some of our friend will register and be schooling, but when they start or find themselves with such life they don’t think about school anymore.”

Symptoms of addiction, such as tolerance and withdrawal, obsession with procurement of the substance of choice, and impaired judgment and decision-making seemed to be more associated with individuals who dropped out of school.

“That’s every day, sometimes she drinks constantly, and she comes from school, sometimes she can’t go to school. I try to talk to her, but she can’t even listen to me. She is not in school anymore.”

When compared with students who were expelled from school due to substance-related misbehavior. Some students did not drop out of school until after high school.

“Some have graduated from high school and are in the University of Liberia, but they end up dropping out.”

Although students did not always indicate the reason for dropping out of school in the transcript narratives, it did seem to be related to a conscious choice on the part of the individual. Like expulsion from school, dropping out of school could lead to the individual ramifications of prematurely halting one’s education, and mitigating the protective benefits of staying in school.

Consequences of substance use – school milieu

Ingesting an unknown substance: Another consequence associated with concealing alcohol and drugs and bringing them to school was that other students might unknowingly ingest a particular substance.

“They are some people who make tea with opium. Sometimes they put it in food, like kanyan and you eat it without knowing it.”

Students described, “Not being yourself ” if they were to consume foods or beverages tainted with a substance such as opium. Students indicated that they often learned to stay away from foods that were commonly used to mix substances in such as kanyan. Thus, concealing alcohol and substances and bringing them to school not only led to individual consequences associated with intentional intoxication, but also led to other students within the school milieu unintentionally ingesting substances as well.

Unintentional ingestion of alcohol and substances was also associated with intoxication and subsequent ‘misbehavior’.

“They bring the clear cane juice (undiluted alcoholic beverage brewed in Liberia), and put kool aid in it so people think its juice. They drink it and start misbehaving all over the place.”

Students did not describe any additional consequences associated with unintentional ingestion of substances such as confrontations with the teacher, expulsion, or dropping out of school. As such, unintentional ingestion did not appear to follow the same consequence trajectory of individual students who were knowingly using substances. However both intentional and unintentional ingestion of alcohol and substances were described as leading to intoxication and misbehavior, both of which were described as important consequences leading to disruption of the school classroom environment.

Disruption of the school classroom environment: Overall, students felt that substance use was problematic in the school classroom environment.

“Actually this smoking business is very much affecting us especially in this school I must admit.”

Misbehavior by students who were intoxicated led to important individual consequences as previously described, but was also felt to have a negative impact on the learning environment for the entire class, and thus was an important outcome of substance use that affected other students proximate to the misbehaving individual.

“I feel bad for myself to see disgruntle men in the class who drink alcohol and misbehaving while teacher is impacting knowledge in us.”

Consequences associated with substance use in the school classroom environment were aggressive behaviors and disruption of the learning environment.

“The last time a teacher entered in class and a boy took the opium and drank the liquor, he started misbehaving. So when the instructor tries to put him outside, he started to fight the man and he slams the door almost to knock the instructor’s face.”

“Yes, that’s the noise making people and when they take in the alcoholic drink and the drugs, they can be there and disturbing.”

Students reported that their classmates intoxicated by drugs or alcohol disrupted other students’ ability to learn.

“And those of you who are paying full attention to the teachers; they will decide to distract your mind from the teaching and to disturb you people.”

Students in many of the focus groups described witnessing teachers as being targeted with aggressive behavior by their substance-using peers. However, it was unclear whether students were concerned about their safety or not. Students clearly described the school milieu and their learning being disrupted, and being distracted by their peers who were ‘misbehaving’.

Protective factors against substance use

School as a protective factor against substance use and other high-risk behaviors: Students believed that school was could serve as a protective factor against engaging in substance use.

“Yes, being in school will keep me from doing these things.”

As previously described substance use and truncated schooling also seemed to be associated with increased risk for other consequences such as criminal behavior (stealing/theft) as well as unplanned and unwanted pregnancy.

“The people that use drugs, they don’t plan their future. Some of them pregnant people and they go and stand and say not me pregnant.”

One student highlighted this by describing the protective influence of teachers and school on preventing unplanned pregnancy.

“My teacher can advise me. They can say wait for your time, go to school. When God helps you and you finish school, God will give you your own partner, because when you rush sometimes people will easily pregnant you.”

School was also described as an important place to learn about, HIV/AIDS, other sexually transmitted diseases, and safe sex practices.

“It’s (condoms) to protect you from AIDS, gonorrhea, and others. My former study class teacher taught me biology and told us about condoms.”

Expulsion from school would possibly limit opportunities to educate school-aged youths about sexually transmitted diseases (STD’s) and safe sex practices.

School, substance use, and the future

School was also described as protective for one’s “future”, and the protective benefits of staying in school were less likely to be conferred upon students who were either expelled or who chose to drop out of school prematurely.

“For example, if I’m kicked out of school, and I’m being ill-treated, I could drop out of school and find some time to take up my time and end up being on the streets, and start drinking, stealing, etc.”

Students in these focus groups associated their “future” and their classmates “future” with school.

As previously discussed, students felt that being in school was protective against detrimental outcomes such as continued substance use, violence and criminal behavior, as well as unplanned or unwanted pregnancy. Students also described school as a means to providing opportunities, and improving their status in life.

“Yes when you want for you to go to school, you plan your future because you in your family, you want to be the head, of course you’re small but they will respect you; so long you finish with school, you working, you get money, you will see all you people coming around you.”

Students who were motivated to learn felt that school was important to their future, as well as having a classroom environment conducive to learning.

“So I feel that this program is very important for us who are really willing to learn.”

Collectively students viewed school as benefiting their “future” when referring to the protective as well as cultivating aspects of school. Conversely, students felt that consequences such as prematurely exiting school (expulsion or dropping out) or disruption of the classroom-learning environment were adversely affecting their friends’ future.

“No, not because it (substance use) is causing me problem, because I am afraid because it (substance use) is damaging our friend’s future.”

Some students also seemed to have a sense that consequences of substance use among school-aged youths in schools could not only adversely affect them or their friends and classmates, but was also having a larger impact on their country’s future that they were a part of shaping.

“It makes me to be embarrassed because young men like myself could be leaders of this country so to see them doing such things means that no one will be able to rule them in the future.”

The public health impact of substance use among youth in post-conflict societies, particularly Liberia, is not well understood [ 18 , 19 ]. Thus, we hoped to learn more about students’ perceptions regarding consequences of substance use in the school setting in Liberia using a small focus group setting. We chose a focus group methodology as a means of interviewing a small group of participants in a less anxiety provoking setting as substance use could be a potentially difficult-to-discuss topic [ 15 , 16 ]. Other studies using focus groups have found this method to be effective in soliciting a richer and more diverse participant narrative when compared to individual interviews asking similar research questions [ 15 , 16 , 20 , 21 ]. Qualitative studies such as this could also be helpful in developing more culturally specific and meaningful epidemiologic questions when developing larger quantitative public health research methodologies.

Marit Woods wrote about the importance of incorporating Liberian youths into the post-conflict reconstruction efforts, a position subsequently echoed by Liberia’s president [ 4 , 22 ]. The importance of well-educated youths to the country’s post-conflict recovery, and potential implications for other countries with a similar geopolitical and socioeconomic make-up makes understanding the consequences and impact of substance use among youths attending school in Liberia a germane focus of study. In this study, students from three public schools in Monrovia, Liberia described four themes associated with substance use in the school setting – behaviors, consequences of substance use affecting individuals using substances, consequences of substance use affecting those proximate to the substance-using individual within the school milieu, and the school environment as a protective factor.

Although there is a large amount of data published on the consequences of substance use among adolescents and young adults globally, there is very little data regarding the contextual and cultural variables of substance use in Liberia, particularly in relation to Liberia’s post-war status [ 19 ]. For example, students often used culturally specific phrases and idioms of distress when describing behaviors or consequences related to substance use in the school setting. The term ‘weesie’ referred to getting high or becoming intoxicated, and the phrase ‘it becomes a part of you’ seemed to refer to symptoms of addiction. The term ‘opium’ was often and somewhat confusingly used as a synonym for marijuana, which is documented in other studies as well [ 18 ]. Therefore, understanding how culturally specific expressions, local customs, and attributions shape perceptions of behaviors and consequences is critical to developing relevant epidemiologic tools to better understand such behavior as well as developing meaningful strategic interventions [ 23 , 24 ].

In many African countries youths tend to be marginalized, which further exacerbates many socioeconomic consequences such as unemployment, exposure to violence/crime, and lack of societal engagement [ 22 ]. Indeed, study participants in these focus groups described violence, particularly sexual violence towards women, as well as other criminal behaviors such as theft in connection with substance use and truncated schooling. Importantly, students also felt that parents were unaware that substances were being concealed and brought to school, which is perhaps a reflection of lack of parental and family involvement.

In this study, substance use in the school setting was associated with important individual consequences, such as intoxication, risk for developing addiction, misbehavior and confrontations with the teacher, and decreased motivation to attend school which in turn led to premature exiting from school, and increased risk for engaging in deviant behaviors. Conversely, students perceived that school was protective against violence and juvenile delinquent behavior. These findings are supported in the literature that describe actively engaged families along with high academic achievement, and motivation to learn in school, as being important protective factors against juvenile delinquent behavior [ 25 ]. The latter findings are particularly important, in that they support the importance of a school classroom environment that is safe and conducive to learning, something that students also described as being adversely affected by substance use in the school setting.

Individual consequences associated with substance use in the school setting seemed to begin with clearly described behaviors associated with substance use which involved students concealing substances and alcohol and bringing them to school. Students described concealment of substances in their school bags, or mixing opium in with popular snack items such as kanyan or various beverages including juice and tea. Students described one instance where a ‘gate man’ or school security officer seemed to be aware of this behavior and allowed students outside to use the substances, but no indication of consequences was mentioned in that particular narrative. In private schools, students were described as using substances in school and bribing teachers to avoid consequences. Students also described being wary of consuming kanyan or juice at school out of fear that they may unknowingly ingest a snack item mixed with opium or other substance and become intoxicated even as early as elementary school. What was unclear is how common such behavior was, and to what degree this behavior was viewed as socially and culturally normative by students and school officials. These are important research questions for further study.

Students described various reasons for bringing substances to school ranging from helping them to overcome social anxiety to self-treating mental illness such as post-traumatic stress disorder (PTSD) and major depression. PTSD and major depression are common conditions connected with witnessing or being associated with atrocities of past conflict [ 26 ]. In some cases students made reference to some of their classmates serving as “child soldiers”, where substance use was very common in programming and desensitizing these individuals [ 27 , 28 ]. Other students simply indicated that they wanted to “disturb” the class and confront their teachers. Whatever the reason for bringing substances to school a direct consequence of this behavior described by students was either knowingly or unknowingly becoming intoxicated.

Previous research has found that substance use and intoxication from alcohol and cannabis in the school setting is associated with a number consequences including increased likelihood of heavy drinking over time, increased rates of school dropout, increased high-risk behaviors, and decreased development of positive peer relationships [ 25 , 29 ]. We did find that substance use among school-aged youths was associated with choosing to drop out of school, whether due to development of addiction, or lack of motivation, or some combination of factors. Students described high-risk behaviors associated with truncated schooling such as increased sexual behaviors and unplanned or unwanted pregnancy, which was consistent with other studies [ 30 ]. Students discussed their concerns that intoxication from alcohol and substance use led to changes in their classmate’s behavior, disruption of the classroom setting, and that alcohol and substance use was associated with suspension/expulsion or dropping out of school.

Disruption of the classroom setting and subsequent mandatory interruption of school attendance or removal from school altogether are important consequences that have individual, environmental, work force, and societal ramifications [ 5 – 7 , 25 ]. In this study, students described substance-use related disruption of the classroom setting as having both individual as well as classroom milieu consequences. Students cited disruption of the classroom setting as a reason for discipline from the school including suspension or expulsion. Students described different examples of intoxicated students who would confront teachers in school, which led to suspension or expulsion from school. Teachers were not interviewed to learn about their perspective when intoxicated students confronted them, as this was not the focus of our study, but would be important for future studies.

Other forms of intervention for managing disruptive students included transferring a student to a different school. This was also associated with the socioeconomic disparity among public school students with more affluent students tending to be transferred to private schools, and other students simply being expelled from school. This may reflect general uncertainty as to how best to respond to the disruptive student especially when associated with alcohol or substance use.

Expulsion of students of privilege, students whose parents were sufficiently affluent enough to send them to private school, who were using substances was not only viewed as an ineffective individual consequence but in fact seemed to enable the behavior, and in some cases placed the individual at increased risk for addiction with recurrent substance use, as private schools were viewed as more accepting of student substance use. Conversely, expulsion of students of lower socioeconomic status could place school-aged youths at increased risk for violence and other consequences associated with substance use on the streets, in addition to the individual consequence of halting that student’s schooling.

Suspension, expulsion, and dropping out of school are all particularly concerning consequences due to the high rates of unemployment among Liberian youth and the vital role that education could play in improving the post-conflict Liberian economy. In this study, students believed that alcohol and substance use occurred frequently on school campuses, although our study design did not allow us to quantify this perception. Students also believed that peer alcohol and substance use was adversely affecting their future. Students also clearly describe school milieu consequences such as disruptive behavior secondary to peer alcohol and substance use. Specific consequences described by students included decreased quality of learning, and confrontations with school teachers.

This is a challenging dilemma without an easy solution. In other countries brief school based interventions for substance using adolescents have been trialed with mixed results [ 31 ]. This study was not designed to determine the frequency of school suspension, expulsion, or dropouts associated with alcohol or substance use, which would be an important follow up research question. Another significant concern is how these disruptive behaviors affect the quality and safety of the school environment, and the impact this has on education and the future of young people who are motivated to learn. Previous studies have cited poor quality of school environment and lack of schoolteachers as important school-related factors that influence poor attendance among Liberian school students [ 32 ].

Students had some sense that alcohol and substance use in school was affecting their future, which may be a protective factor. Student engagement could serve as an impetus for school students to become actively involved in developing strategies and interventions to reduce alcohol and substance use in the school settings. What is unclear from this study is the importance of alcohol and substance use in school settings relative to other challenges school students in Monrovia face.

Limitations

This was a relatively small, qualitative study that used focus groups to gather information about important themes related to substance use in the school setting from public school students in Monrovia, Liberia. As described in other qualitative studies strength of opinion was difficult to determine within focus groups as solicited opinions are context-specific and may not accurately reflect how strongly held a particular belief is [ 18 , 19 ]. Larger and more targeted epidemiologic studies are needed to confirm these results and identify strategies for further education about substance use in West African schools, promote harm reduction, and reduce substance use in the school setting are needed to confirm and expand on the results reported in this study. Additionally, this study was not designed to detect the frequency of behavior or consequences associated with alcohol or substance use among school students, and as such we attempted to highlight important follow up research questions raised by this study throughout the discussion.

One of the challenges of cross-cultural research is obtaining data that is both accurate and meaningful to the country and culture of study. Although there have been numerous studies investigating substance use among youths in the school setting world-wide, there is a paucity of data among Liberian schools and students. While this highlights the importance of studies such as ours, it is also a key limitation when attempting to make inferences from other studies and applying them to our cohort population.

We also note that for purposes of standardization world bodies such as WHO, United Nations (UN), and United Nations Children’s Fund (UNICEF) collectively use the term ‘youth’ to refer to persons ages 15–24, although individual societal variation of the term ‘youth’ is commonly recognized [ 5 , 33 ]. Our group of study participants ranged in age from 12–20 approximating the standardized age range of the term ‘youth’. Developmentally speaking the term ‘youth’ was intended to capture a cohort of persons who fall between the life-stages of leaving mandatory education and first becoming employed [ 33 ]. We have used the term ‘school-aged youths’ as this was the developmental categorization that best described our study participant cohort, but recognize that this may be a potential limitation when comparing this study to other studies using the term ‘youths’.

A better understanding of important themes associated with substance use among Liberian school-aged youths and how they affect individuals and the school environment is critical to developing public health strategies to address this issue. This study highlighted important behaviors and consequences of alcohol and substance use among school students in Monrovia, Liberia, and underscored the importance of school as a protective factor that is important for the future of young people. This study provides a further understanding of the important problem of substance use, and may lead to the development of appropriate and meaningful intervention strategies in Liberia, and could have implications for other countries with similar profiles.

Acknowledgments

The corresponding author is supported by a NIH grant (#5K01MH100428).