Why are Youth Engaged in Substance Use? A Qualitative Study Exploring Substance Use and Risk Factors Among the Youth of Jimma Town, Southwest Ethiopia.

INTRODUCTION: Substance use refers to the use of psychoactive substances such as khat, alcohol, cigarettes, and illicit drugs. Young people are more vulnerable to substance use than older people. Substance use has varying impacts on the health and socio-economics of countries, and is a major public health concern globally. Currently, substance use is a common public health concern among the youth of Ethiopia, mainly in Jimma town. Therefore, this study aimed to explore the substance use and risk factors among the youth of Jimma town in 2019.
METHODS: The study was conducted in Jimma town among youth who were engaged in substance use, from March to April 2019. A descriptive qualitative study design was employed and the study participants were acquired using purposive/judgmental sampling techniques. In total, 20 interviews were conducted with young people using in-depth and key informant interview methods. The data were analyzed by using ATLAS.ti version 7. Thematic analyses were performed in order to extract the main themes and categories. Direct quotations were presented with a thick description of the findings.
RESULTS: The findings of this study were discussed under six themes and 12 categories, which emerged from thematic analysis of the data: substance use setting, time and means of distribution, substance-related factors, social and economic factors, individual factors, psychological factors, and legal and policy factors.
CONCLUSION: The study indicated that khat, alcohol, cigarettes and shisha or water pipes were the most commonly used substances. Different factors that drive the youth to engage in substance use were identified; individual factors, social and economic factors, substance-related factors, and legal and policy factors were most common. Generally, to overcome this problem, the community, lawyers, and policemen should participate in the implementation and enforcement of rules and regulations on substance use. Family should monitor their children and need to act as good role models by avoiding substance use.

Introduction

Young people are a broad age group with a lot of roles and responsibilities. They are more likely to use substances, and are at high risk of engaging in substance use which has various impacts on their physical and mental health, as well as their socio-economic and academic achievement.1 Substance use refers to the use of psychoactive substances such as cigarettes, alcohol, khat, over the counter drugs, prescribed drugs and illegal drugs.2–5 Psychoactive substances cause dependence syndrome due to repeated use.6

Surveys conducted regarding substance use among general worldwide populations show that the extent of substance use among young people remains at a higher rate than among older people, although there are some exceptions associated with the traditional use of drugs such as opium or khat.6 Literature suggests that early (12–14 years old) to late (15–17 years old) adolescence is a critical risk period for the initiation of substance use, and that substance use is highest amongst young people aged 18–25 years.7

In Ethiopia, addictive substances such as khat, tobacco, and alcohol are widely used by adolescents and youth. About 4.4% of Ethiopian adolescents and youth smoke cigarettes or other tobacco products.8 The practice is more common among urban adolescents and youth. Nearly half (45.6%) consume alcohol more than six times a month. The prevalence of alcohol consumption is higher among male (47.7%) than female (43.5%) adolescents and youth, and higher among rural than urban residents.8 Recent evidence shows that 36.6% of adolescents and youth of between 15–29 years in age are consuming any form of alcohol, with a prevalence which is higher among males (42.6%) than females (29.5%).9

The national prevalence of khat consumption among adolescents and youth is 51%; this is higher among males (56.5%) than females (36.6%). Among current 15–29-year-olds, the average age of starting to chew khat is 16.9 years.9 The meta-analysis performed regarding the magnitude of substance use among the youth of Ethiopia identified different factors that drive youth substance use at different levels, including socio-demographic disadvantage, family history, peer influence, community norms, living patterns, and stress. It also identified different protective factors like religiosity, better social skills, and risk perception.10

This study was initiated based on the following rationale. First, substance-related problems are not addressed well, and currently the problem is alarmingly increasing in Ethiopia. The Ethiopian minister of health identified substance use as a problem amongst the youth and adolescents,11 and the Jimma zone health bureau also identified this as a major problem among youth, along with HIV/AIDS. This study has also attempted to identify the underlying factors for substance use among high-risk groups, by employing a purely qualitative study. Thus, a study on substance use and risk factors among the youth is important to reduce the social, economic, and health-related problems associated with substance use including khat chewing, alcohol use, and cigarette smoking. Although a lot of quantitative studies were conducted and published on substance use and associated factors among high school and university students in Ethiopia previously, few qualitative studies have been conducted on substance use and risk factors among the youth in Ethiopia, and none were conducted in southwest Ethiopia. This study is therefore exploring the underlying causes or risk factors for substance use.

Methods

Study Setting and Period

The study was conducted in Jimma town. Jimma town is located in the Jimma zone, Oromia regional state, southwest Ethiopia. Jimma is the capital city for the Jimma zone and it is located 345 km from Addis Ababa, the capital city of Ethiopia. The Jimma town population predominantly originates from the Oromo ethnic group. The town has 17 kebele, with a total population of 205,163, of whom 102,007 are female 103,156 are male, and the total number of households is 42,742, according to the 2019 Jimma zone health bureau projection population report. Of the total population, around 40,539 (21%) are youth (aged 15–24). The study was conducted from March–April 2019.

Study Design

A descriptive qualitative study design was employed, which allowed for the understanding and description of risk factors associated with substance use among the youth of Jimma town. This study follows the standard protocol for qualitative studies, COREQ (consolidated criteria for reporting qualitative research) for reporting qualitative findings.

Population Requirements

The youth who use substances and live in Jimma town, with varying socio-demographic statuses, and different key informants were interviewed for this study. Interviewees were recruited from the Jimma town youth association, the Kebele youth association, the Jimma town children, adolescent and youth health office, non-governmental organizations (NGOs) which work on substance use privation and psychiatrists working in rehabilitation centers. Accordingly, Twenty interviews were conducted for this purpose. More specifically, 15 in-depth interviews (IDI) were conducted with young people from Jimma town who use substances, and five key informant interviews (KII) were conducted with different key informants. The Jimma town youth association chairman, Kebele youth association chairman, Jimma town health office child, adolescent, and youth health focal person, the NGO work on substance use privation focal person and a psychiatrist who works in a substance use rehabilitation center were involved in this study.

Data Collection

Semi-structured IDI and KII guides were developed in English by reviewing different kinds of literature and translated into Afan Oromo and Amharic languages. The interview guides were evaluated by qualitative experts from the Jimma University department of health, behavior, and society. The tool was pre-tested on two participants before actual data collection. The interview guides included questions about demographic information, commonly used substances, location of substance use, time of substance use, risk factors for substance use, and substance use prevention methods (See underlying data). The data were collected through face to face interviews. These interviews were held using a semi-structured interview guide, prepared in English and translated into the local language (Afan Oromo and Amharic). An IDI was conducted by the qualitative experts and through note-taking and tape-recording. Interviews were conducted at convenient time as selected by the participants.

Data Analysis

The interview data were first transcribed verbatim in two languages – Afan Oromo and Amharic, by which the interviews were conducted. Next, the data were translated into English by language experts. Then translation was copied to the ATLAS.ti version 7 for analysis. The researchers conducted qualitative data analysis using inductive thematic analysis, which aimed to identify a set of main themes which captured the diverse views and feelings expressed by participants. Thematic analysis is useful for summarizing key features of a large data set, as it forces the researcher to take a well-structured approach to handling data, helping to produce a clear and organized final report.12 The transcripts were read by the research team before the actual coding began in order to identify important topics and create a code book. The transcripts were coded by all members of the research team. To improve inter-coder reliability, the coders each used the code book independently and disparities in coding were solved by discussion. After that, a final edition of the code book was developed, and categories and themes were constructed. The coded transcripts were further analyzed and summarized in narratives for each theme and categories. Direct quotations were presented with the thick description as findings.

Trustworthiness

To maintain credibility, in-depth and KII guides were evaluated by qualitative experts from the Jimma University department of health, behavior, and society. The data collection tool (interview guide) was pre-tested on two participants before actual data collection. Specifically, IDIs and KIIs were conducted with a young person and a key informant who both live in Agaro town. The tool was then modified following a discussion with research team members. To diversify the study participants, the young interviewees and key informants were recruited based on a socio-economic characteristic (age, sex, educational status, and occupation) in order to get a broader range of viewpoints from different participants. To assure member checking, the transcription and translation were shared and a summary of core points and some confusing ideas were presented to the key-informant and in-depth interview participants. Then, they provided their comments and critiques on the raised points, and the consensus was made on some unclear ideas. The final result of the study was shared with all study participants to confirm that their ideas had been represented accurately.

To maintain transferability of the overall research process, study setting, and study participant characteristics were well stated in the methodology part. During data collection, probing interview techniques were used between each question, which involved asking further questions in order to understand factors associated with substance use. The data collectors used a tape-recorder and written field notes to record the interviews. Finally, the thick description was completed. To maintain dependability, a member check was performed by the participants to check and verify the interpretations and findings.

To maintain conformability different techniques were used. The first technique was researchers’ self-reflection and bracketing. The principal investigator was a public health professional and currently has a master’s degree in health promotion and health behaviors. Additionally, the principal investigators have good experience in qualitative research. This experience and specialization were important in order to address the research question appropriately. The other research team members have educational backgrounds in health and specialize in health promotion and health education. All have good experience in qualitative research.

The context of this study setting was different from the setting in which principal investigators have been working and living. The KII and IDI participants were not familiar with the principal investigator. To minimize researcher bias, different efforts were made by the principal investigator. The principal investigator tried to set aside their assumptions, perceptions, and values, and prior knowledge during data collection, coding, and analysis. The data collection assistance and principal investigator know the local language fluently. This is important to minimize interpretation bias. But, we are not overconfident while interpreting the findings and attention was taken to balance interpretation with direct quotations from the study participants.

The other technique was peer debriefing, performed by the qualitative expert of the Jimma university department of health behavior and society, which mainly focused on qualitative data coding and analysis. The last technique was prolonged engagement. Prolonged engagement was achieved by staying in the study area for a long time. During this time the principal investigator confirmed the points raised in the IDIs and KIIs. He observed and confirmed different issues like substance availability, means of substance distribution, places in which substances are used, and weak legal control of substance users.

Results

Characteristics of Respondents

There were a total of 20 participants in this study, which included 15 IDIs with young people and five KIIs. The demographic characteristics of the participants were summarized in Table 1.

Table 1

Socioeconomic Characteristics of the Study Participants

Variables	Categories	Frequency	Percentage
Sex	Female	6	30
	Male	14	70
Marital status	Single	10	50
	Married	10	50
Level of education	<10	2	10
	Diploma	2	10
	Degree	12	60
	Masters and above	4	20
Total		20	100

The findings of this study were discussed under six themes (substance use setting, time and means of distribution, substance-related factors, social and economic factors, individual factors, psychological factors, legal and policy factors) which emerged from the data analysis (Table 2).

Table 2

List of Themes, Categories and Codes

Themes	Categories	Codes
Substance use setting, time, and means of distribution	Substance use setting	Khat and shisha houses, entertainment areas, residential houses, hotels, on the main roads etc.
	Timing of substance use	Afternoon, at night, weekend times
	Means of substance distribution	Khat tera, shops, bars, hotels etc.
Social and economic factors that promote substance use	Social factors	Family substance use, family instability, the over-control of children, friend substance use, media effects etc.
	Economic factors	Lack of job, nature of job, lack of recreational areas etc.
Factors related to the individual that promote substance use	Personal related factors	Lack of knowledge, assuming substance use as a civilized activity, academic failure, individual interests etc.
Psychological factors that promote substance use	Psychological related factors	To relax, drive happiness, temporarily forget problems, get relief from stress, resolve depression etc.
Substance-related factors that promote substance use	Availability of substances	Easily available, available all of the season
	Affordability of substance	Available in low price, buy in group
	Effects of other substance using	Effects of other substance using
Legal and policy factors that promote substance use	Legal related factors	Poor legal practice
	Policy related factors	Lack of strong policy

Theme: Substance Use Setting, Time, and Means of Distribution

Substance

The participants reported diverse substances commonly used in Jimma town. Accordingly, khat, cigarette, alcohol, shisha, “mastish” (shoe glue), and “ganja” were commonly used substances. According to participants, the most commonly used substance in Jimma town was khat, followed by alcohol, cigarettes, and shisha. A substance like hashish was frequently used by university students.

Khat, alcohol, shisha and cigarette and others are a substance which induces addiction and commonly used by the Jimma town youth. (a female in her early 20s, IDI participant)

These findings indicated that substance use is a major problem among the youth of Jimma town. The participants reported that substance use among the youth was increasing. According to interviewees, some students start using substances right from the elementary school level.

… khat and shisha are the most commonly used substances by the youth of Jimma town … the majority of them start substance use at elementary school. (35 years old, male KII participant)

Substance Use Settings

The youth and key informants believed that substances are frequently used at khat and shisha houses, entertainment areas, residential houses, coffee and tea shops, hotels, on the main roads, at the work area, and in green areas. The youth often use the substances in places where they can be with friends or where their privacy can be kept. An interviewee said that:

… I use at places where I can get a good khat. Sometimes I use at khat chewing houses because no one knows me there and I join my friends. I’m happy when chewing khat with my friends. (20 years old, male, IDI participant)

It was reported that the place of substance use may vary based on individual and group interests. Some youth use substances in entertainment areas. Others use at workplaces or secure areas. Depending on their level of income, some individuals use substances at shisha houses. The youth who do not have income chew khat on the streets. Some students rent private houses around Jimma University or college that serve as a chewing room for groups. A participant reported that substances were used everywhere in Jimma town:

Well … it can be said everywhere. … it is tea and coffee shops everywhere, established in the town for using substances. There are also identified shops where Shisha are smoked. The most commonplace and comfortable area for chewing is an individual’s home. (35 years old, male, KII participant)

Timing of Substance Use

The majority of the participants believed that substances were frequently used by the youth in the afternoon, at night, and during the weekend times. The time favored by the youth to use substances all depends on individuals’ behavior and the nature of their job. Some individuals use khat during the morning time – they call it “ijabena” (a stimulant). However, the majority of the youth use khat in the afternoon because it is normally transported and available in the markets during the afternoon time. Some participants reported that substances are also used during morning times and frequently on Saturdays.

When young people [students] do not have a program during the morning session, they soon arrive at the khat vendor house and enjoy chewing. The employed youth often chews Khat between five and a half hours to seven and a half and return to work. Those guys without jobs and daily-laborers use chewing at any time. But, the time when this youth meet is varied; at all, it seems they use Khat the whole day. (28 years old, male, KII participant)

Substance Means of Distribution

All participants thought that common substances like khat, alcohol, and cigarettes are distributed legally. These substances have a particular transaction place and the individuals engaged in these businesses have to pay tax to the government. However, all participants confirmed that substances like shisha are distributed in an illegal way or by means of contraband and distributed to the consumers at secretive places. Khat has its own place of distribution known as the khat “tera” (khat selling area). Users buy from this area. Cigarettes are available at almost all shops. Alcohol is available at all bars and hotels. Khat is produced by local farmers at rural kebeles and sellers buy from the farmers. It reaches the town by different transportation means and at the khat “tera” the sellers sell to consumers based on individual interests and affording capacity:

… If one person needs shisha he/she goes to a shisha house and orders shisha full or half based on her/his interest. But it is illegal. It was sold secretly. However, other substances like khat are available in the market in legal form. It is traded publicly at khat shops and the government collects tax from the traders. Khat is also sold at different places … on the street, personal residential areas, and khat are available at all places in Jimma town. Alcohol and cigarette are also available at everywhere in town (35 years old, woman, KII participant)

Theme: Social and Economic Factors That Promote Substance Use

Under this theme, two categories emerged, namely social factors and economic factors.

Social Factors

One category that emerged under the social and economic theme is social factors. Most of the youth and key informants interviewed said that the main factor for using substances was family substance use, family instability, the over-control of children, friend substance use, media effects, and social norms. It was learned from the interviews that the way in which family raised their children was a factor for using substances. If the child’s father smokes a cigarette, the child becomes a passive smoker at first and starts smoking at a young age. Children inherit their family’s behaviors. It means that if families use khat, the possibility of the children using substances is high. Similar views were reflected by participants:

… Children follow what their families do. It means, in short; if some of their family’s members use the substance, the children will do the same. This is the main factor … (46 years’ old, male, KII participant)

At first chewing, khat has long become a traditional practice in this area and youth inherit from their family who chew khat or use substances. (28 years old, male, KII participant)

Family instability was reported as a factor for using substances. In an unstable family, the youth sometimes loss hope, detached from their family, and start to live with their friends. Such practices lead them to use substances, particularly if their friends might use the substances previously. On the other hand, those children brought up in wealthy families with strict over-control and follow up were more vulnerable to substance use. The main reason is that they start to use substances when they get relative freedom in schools. Therefore, as the child grows, it is important to teach them “right” and “wrong”.

Another factor identified as a case for using a substance is fellowships/friends. A psychiatrist argued that

… I can definitely tell you that the person, who fraternizes with an addicted person, would soon become addicted. Others, as well, choose to imitate those habits and eventually submerge to addiction (28 years old, male, KII participant)

Most of the youth and key informants interviewed believed that the main factor for substance use was also associated with social norms. It was also reported that substance use was associated with community norms. For example, in Jimma town, khat is commonly used by all people. Because of this factor, at first, people try khat after seeing it being used by other persons. After a while, they start to use it like other individuals. Thus, they consider using the substance to be normal practice.

… old man, young, teacher, and students use substances, so children take substance as a culture. Our father and grandfather take substances as gifts for people for different ceremonies and occasions. Therefore, following families’ practices, the youth start to use substances. (19 years old, female in-depth interview participant)

The other participant in the study reported that:

… In the country, a lot of people drink alcohol, and drinking alcohol is considered a culture. In Jimma, most people are chewing khat, and often it is regarded as a good culture. This motivates the youth to chew khat. (46 years old, male, KII participant)

The other issue found under social factors is religion-related factors. Some of the interview participants thought that substance use was related to religion. Contrary to this, others argued that religion is a protective factor for substance use. These two views were summarized as follows:

… Substance use is associated with religion. All religions said drinking alcohol is a sin, but by neglecting this rule some people drink alcohol. Khat is used for praying and the so-called ‘duway’ is widely practiced with this substance. But religion does not command this. (28 years old, male, KII participant)

… Church advises the youth not to use the substance. Religion plays a greater role than government in this regard. Therefore, if religious organizations provide advice for youth, great change will occur. (20-year-old, male, IDI participant)

Economic Factors

The participants reported different factors for substance use. From these, the economic factor was identified as an activating factor for substance use. Lack of job (unemployment), nature/type of job, and lack of recreational areas were reported as stimulating factors. One of the IDI participants reported that he uses substance because of the nature of his work and workplace:

… The main reason why I use a substance is associated with my work. As I told you before, I am a waiter at a shisha house. Thus, it is very difficult for me not to use the substance as long as I am in this house. If you have a strong motive not to use the substance, some person enforces you to start it. (19 years old, female, IDI participant)

The other reason for using substances was reported in relation to lack of job opportunity. They complained that the youth use substances because of a lack of job opportunities. If they get job opportunities, it makes them busy and they do not get time to use substances. As well, other participants of the study complain that:

… One who is left without a job, is inclined to chew khat as a means of recreation, and to spend their time. Others with careers would spend their entire hours on their duties. So, this could directly be connected with joblessness, numerous questions, complaints … (28 years old, male, KII participant)

Another finding reflected from a KII participant is:

A more critical problem for the young generation as a whole is joblessness. As we all know, as the majority of the young generation are left without jobs, and their fate is escorted by numerous problems, the sole option to cool down their stress and anxiety and the one and undeniable means for them is chewing and then drinking and possibly unsafe sex practices. (35 years old, male, KII participant)

The other reported factor was the lack of youth entertainment areas. There are few recreational youth centers in the town. If the youth has an entertainment center with different services like internet, libraries, and different game zones, these substantially reduce the problem of substance-use in the Jimma area.

Theme: Factors Related to the Individual That Promote Substance Use

Personal Related Factors

In the interviews conducted with the youth, it was identified that personal factors can possibly contribute to substance use. The main individual factors reported were a lack of knowledge and awareness about the effect of the substances, assuming substance use as a civilized activity, academic failure, and individual interests. An interview participant associated academic failure with substance use:

I started using substances because I was not successful in grade ten national examinations and I have no work. I come to this area (khat house) and I chew it with my friends. I spend time here by enjoying myself with them. (20 years old, male, IDI participant)

The youth involved in the interview admitted that the majority of them did not know the effect of substance-use at the beginning. Some of them start using a substance without knowledge and it becomes difficult for them to stop it. They suggest that it is better to promote and teach the effect of substance use through different media. A user who participated in the study said that:

When I started using substances, I am an elementary student and I didn’t know the effect of the substances. I saw from my friends and start using “mestush”, but I don’t have any knowledge about the effect of this substance. If I knew the effect of the substance, I might not use it. (23 years old, male, IDI participant)

The study also identified that the youth imitate each other’s behavior in using substances, by considering such practices as “modernization”.

… Most of the youth start using substances due to a lack of awareness, and some of them consider substance use as modernization. (46 years old, male, KII participant)

Theme: Psychological Factors That Promote Substance Use

The fourth theme is the psychological factor. The participants believed that psychological factors encourage the youth to be engaged in substance use.

Psychological Related Factors

The study revealed that the youth use substances to relax, drive happiness, temporarily forget problems, get relief from stress, resolve depression and anxiety and also stimulate themselves. Regarding the relationship between the psychological factor and substance use, one participant argued that:

… Psychological conditions and addictive agents are entities that could link each other, one who is highly addicted by those agents appears to be the guy with enormous psychological problems, and the guy with psychological problems’ is supposed to be a highly addicted’ guy. And both are highly interwoven. (28 years old, male, KII participant)

Similarly, participants believed that substance use was initiated to relieve depression or lack of happiness. Therefore, due to psychological problems, some young people start to use substances.

… when people get stressed and need to relax from that issue, they use substances. For example, when you ask a person why he smokes cigarette their immediate response was to relax and forget their problem. (35 years old, women, KII participant)

Besides, an interviewee reflected as:

… Substance use is associated with psychological problems. Truly, it is used for prevention of psychological problems by making internal inspiration. (29 years old, male, KII participant)

Theme: Substance-Related Factors That Promote Substance Use

Substance-related factors are those factors that emerged in the thematic analysis consists of three categories, namely affordability of substance, availability of substance, and effect of using other substances.

Availability of Substances

The findings of this study indicated that the availability of substances (khat, alcohol, and cigarette) in Jimma town was an important factor for using substances by the youth. Most of the study participants indicated that the abundant availability of substances like khat in the local area (community) created a fertile ground to use substances by the youth in Jimma town. The youth participants and the key informant believed that substances are easily available all over the place (at khat shop, on the main road, and khat house). A participant stated that:

Substance is easily available in Jimma for example khat is found everywhere if you went to buy khat you travel only 20 meters from this hotel. Cigarettes are available in all shops and if you need alcohol you get at every 5 meters. (24 years old, male, IDI participant)

A similar view was reflected by one participant as:

… Its [Khat] availability really contributed to using Khat. If khat is not available in Jimma town, you may not go to Agaro or far to buy because you may not afford it. Khat is easily available and the price is affordable in Jimma so everyone can buy and use it easily. (20 years old, male, IDI participant)

One of the interviewees of this study reported that:

Khat is available widely in Jimma town … ‘mastish’ is prepared for making shoe but not for smoking purpose so one can get it easily. Shisha materials enter the country by illegal way or without government knowledge and also shisha cigarette is available on the market illegally. (45 years old male key informant)

Affordability of Substance

This category indicated that substances’ (khat, alcohol, and cigarette) affordability stimulated to easily use substances among youth in Jimma town. Participants assumed that the substance is affordable to the youth of Jimma town at a low price. Even if they do not have money to buy, they manage it by contributing or sharing the cost. Some study participants said that substance like khat is very cheap for every person (youth) to afford it (based on the different seasons, khat price is 30–70 Ethiopia Birr). Supporting this idea, another participant argued that:

… khat in this particular area is so cheaper than anything and they can get it easily, so they get into the addiction circumstances, easily and the very soon. (28 years old, male, KII participant)

In Jimma town, the substance is very cheap and every youth can afford the price, if one of our friends have no money, we use it by shearing each other. (18 years old, male IDI participant)

Some study participants reported that substance like khat is sheared at a group level – people buy it together and chew it as a group. With regard to substance sharing in groups, it was reported that:

… It doesn’t mean all youth are capable of buying khat at all times. As young guys primarily set friendship, two or three of them may have relatively well to do (higher or moderate-income) families, they will cover all the needs of their broke (empty pocket) friends. (28 years old, male, KII participant)

The youth use different mechanisms to get money from different sources, for instance from their parents, to buy substances. Whenever they have no option to afford for substance, they cheat their parents, by telling them false stories. Besides, they commit theft to their parents, and or their neighbors, either money or properties if they have no means of getting the money needed for substances.

Effect of Using Other Substance

The other category that emerged under substance-related factor themes is the effect of other substance using. Participants believe that using one substance, for instance using khat or alcohol or cigarette is a risk factor for using other substances. It was identified that the youth who usually use khat also use cigarette or alcohol or shisha.

… Yes! One substance is risky to use other substance. … I started khat chewing when I was in grade 8 and added other substances when I joined grade ten. I expanded the practice to use other substances like shisha and cigarettes so it can be said that using one substance is a factor to start the other. (20 years old, male, IDI participant)

Similarly, a psychiatrist participant of the study argued that

… all children grow by observing different media like substance advertisement and by watching different movies so this has its own impact on the children mind and it encourages them to use substance at adolescent age. (30 years old, male KII participant)

Theme: Legal and Policy Factors That Promote Substance Use

The sixth theme which was developed from the qualitative data was legal and policy factors. Under this theme, two categories have emerged, namely legal-related factors and policy-related factors.

Legal Related Factors

This category indicated that the legal system was weak on substance control. Different participants believed that legal personnel or policeman’s mal-practices on the controlling of substances were the main factors for increasing the prevalence of substance use in the study area.

… It is clear that the houses that serve for substance use should be installed far away from all educational institutions. Contrary to this, substances were used around schools, colleges, and universities. It was very common to see khat vendors, mini shops (designated for chewing), and shisha houses situated adjacent to these institutions. (28 years old, male, KII participant)

Policy Related Factors

The other categories that emerged under this theme were policy-related factors. Some participants believed that the country’s policy is weak on controlled substance use. A participant from the Zonal health office argued that:

… An increase in the prevalence of substance use was associated with weak government policy. In this town, shisha is available in a different area, smoking shisha is illegal, but legal action is not implemented. Sometimes it is confiscated from the town after someday it is replaced by another. In Jimma, khat is commonly used by all age groups. We must have a rule that restricts to use of substances for under age groups. (35 years old, women, KII participant)

Substance Use Preventive Methods

The study participants suggested different methods that help to reduce the current problem in substance use among youth in the study area. They promoted that enforcing strong rules and regulations on substance use, limiting minimum age on substance use, banning substance advertisements on different media, leave and increasing taxation on substances and increase the price of substances, expanding job opportunities, constructing recreational areas, developing community conversation on substance uses and providing awareness creation education for youth especially at lower grade levels, strengthening the roles of family in guiding and monitoring their children behavior and increasing the role of religious institutions and leaders in educating and advising youth regarding the effect of substance use were forwarded as solutions.

Some participants strongly suggest abolishing khat trees from cultivation land and shifting that land for other crop productions. It is important to limit substance shopping areas and increase the price of substances. Currently, the price of cigarettes is very cheap and every person can afford it including children. Society should act responsibly by not selling cigarettes to underage children (less than 18 years old) and advise them about the effect of substances. It was suggested to impose time on drinking alcohol.

To reduce substance prevalence and related problem the government and the local administrations must be banned and restricted it. (20 years old, women, IDI participant)

The government should work on awareness creation for the youth at lower class levels. It was reported that the youth start using substances when they fail at grade 10 national examinations or when they join campus. So providing education and awareness at lower classes by a psychologist about the effect of substance use is important during the early stages. In awareness-raising attempts, it is advisable to use individuals affected by substance use as examples to teach their experiences. With regard to recreation areas, it was suggested that:

The government should establish youth recreational centers and advise NGOs to work on this important aspect. Only a few NGOs currently work on youth development initiatives. So, the government should give opportunities to the NGOs to work on youth association establishments and education provision. (35 years old, women, KII participant)

As far as the government role is concerned, there should be set concrete rules which are confined to certain agreements. Such agreements should impose sanctions on launching all sources of addictive agents in the nearby educational institutions. The other issue forwarded as a solution was an increment of tax on substances. As the tax is increased in a higher amount, the user’s capacity will highly descend. The other measure that should be sought by the government is to intensify awareness-raising programs. This should run by all means of dissemination. The youth themselves should attempt to communicate and establish a good relationship with different stakeholders, individuals, NGOs, and government sectors that initiated and engaged in some development activities. So that the youth will launch private jobs and seek opportunities and innovative activities. Forming groups and clubs can play a great role in this regard. As for society, individual families and parents should play their pivotal role regarding their children’s behavior. Right from the birth to adolescence periods, parents should guide their children by being a role model and by helping they develop a good personality.

Enacting and enforcing substance law is important to save this generation. Youth engaged in substance use is alarmingly increasing and this risks the country’s development. So the country should have a strong rule to prevent the youth from substance use. If we have strong rules and regulations on substance use, it is very easy to prevent substance use. (40 years old, male, KII participant)

Discussion

The study aimed to explore the substance use and risk factors among the youth of Jimma town. In this study, six themes (Substance use setting, time and means of distribution, Substance-related factors, Social and Economic factors, Individual factors, Psychological factors, Legal and policy factors) emerged. Under the themes different factors for substance use was identified; family substance use, family instability, children over control, friend substance use, media effect, social norms, lack of a job (unemployment), nature/type of job, and lack of recreational areas, lack of knowledge and awareness, assuming substance use as a civilization, academic failure, and individual interests, for relax, drive happiness, temporally forget problems, get relief from stress, resolve depression and anxiety and also to stimulate themselves, affordability of substance, availability of substance, the effect of using other substances, and legal and policy-related factors.

This finding indicated that Khat, cigarette, alcohol, and Shisha were the most common substance used in the study area. This finding was similar to other studies conducted previously in the study area.13–15 This substance was easily available, accessible, and affordable in the study area due to the majority of the local community’s economic dependence on substance cultivation especially Khat was the main produced substance in the study area. So, to reduce the substance available in the study area the agricultural system of the community should replace by other crop products appropriated to the land failed. And also, proper implementation of laws that restrict selling substances to youth, and penalizing substance distributors who do not adhere to the law are essential preventive instruments to reduce youth substance use.

Our study finding indicated that family members (fathers and siblings) substance use is the main factor for youth substance use in the study area. This finding concurrent with the previous study conducted at different counters.16–21 This indicated that most of the youth drives to substance use because of family members (father, mother, sibling, and other relative members) substance use. This is because young people tend to copy and exercise what they observe from their family members. Therefore, to prevent substance use among the youth the family members should act as good role models by avoiding substance use and also strengthening family ties, communication, support, and understanding were viewed as key protective factors.

We found that friend substance use or peer pressure was the main factors for youth substance use, this finding was in line with others study conducted at the different area.16–20,22 This indicates that peer pressure was the main enforcing factor for youth substance use; this is because most of the youth follow the characteristics of their friends and manifested what their friends practice based on shared characteristics. Social network was the main important means for assess of different substance. Hence, to encounter the problem the family should follow and control their child’s daily activity, and school health programs should focus on providing health education focusing on the harmful effect of substance use on health, social life, and economy.

This study finding indicated that social norms (sociocultural) were the main factor for youth engagement in substance use. This finding similar to another study conducted in the different areas.18–20 This indicated that the youth substance use was associated with community cultures; some substance like Khat chewing was accepted by the community norm. In the study area, most of the community uses a substance like Khat for wedding and funeral sermons as a culture to maintain a good relationship with the other, and also Islamic religion follows used substance for Duwa or praying purpose. To overcome this problem the zonal health office should focus on social, behavioral change communication (SBCC), and also health promoters should focus on the dissemination of information on the harmful effect of substance use by using appropriate health learning methods and materials.

Our study finding showed that economical factors or lack of a job (unemployment), nature/type of job, and lack of recreational areas area were the main factors for youth substance use. This finding similar to the other study conducted in a different area.23–25 This finding implies that the youth engagement in substance use was associated with a lack of job and recreation area. In the study area, most youths do not have routine jobs or well-established recreational areas. Having a lot of free time was the main triggering factor for substance use. To solve the problem the zonal sport and youth association should focus on establishing recreation areas and also the zonal micro and small enterprise office should focus on facilitating the job opportunity.

This study revealed that individual factors or lack of knowledge and awareness, assuming substance use as a civilization, academic failure, and individual interests to use substances were the other main factors for youth engagement in substance use. This finding was similar to the other study conducted at different counters.22,23,26 This implicates that lack of knowledge about the harmful effects of substance use on social, academic performance, the economy, and health was the main risk factor for youth substance use. Hence, to overcome the problem health promoter, psychiatrists and sociologists should provide health education on the harmful effect of substance use by focusing on primary school. The health information and communication message should focus on the effect of substance use.

Our study identified that psychological factors were encouraging the youth to engage in substance use; for relax, drive happiness, temporally forget problems, get relief from stress, resolve depression and anxiety, and also to stimulate themselves were the main driving factors to substance use. This finding similar to another study conducted at.23,26 This implies that psychological disorders like anxiety, boredom, stress, and unhappy life were the main risk factors for youth substance use. Therefore to reduce the problem related to substance use the health promoters and psychiatrists should work together to provide health education on the harmful effect of substance use. The government and non-government originations should focus on establishing recreation areas that contain different services, like the internet, game zone, and a library.

Our study finding identified that substance-related factors themes which contain different categories; availability of substance, affordability of substance, and the effect of using other substances were the main factors that encourage the youth to use the substance. This finding was similar to the previous study conducted in a different area.22,23,26,27 This finding indicated that substance availability and affordability was the main factor for youth substance use. Therefore, to reduce substance availability and affordability the government should focus on increasing substance prices and taxes paid for substance production. Also, the government should focus on proper implementation of laws that restrict selling substances to youth and penalizing substance distributors who do not adhere to the law are essential preventive instruments to reduce youth substance use.

Finally, this study finding revealed that youth engagement in substance use was associated with weak legal control of substance use and lack of strong policy to control substance use at the national level. This finding was similar to other studies conducted at the different counters.22,23,27 This indicated that weak legal control on substance use and lack of strong policy to control substance was a key factor for youth engagement in substance use. Hence, to solve the problem the government should develop strong policy and encourage the legal system to control and apply the developed policy.

Strength and Limitation of the Study

This study has several strengths; first, this study focused on the venerable age group (that is youth age 15–24) to identify the underlying factors for substance use. Second, the study participants were recruited from different socio-demographic backgrounds to get enriched information. Third, the data were collected until reach saturation. Fourth few qualitative studies have been conducted on substance use and risk factors among youth in Ethiopia, and none was conducted in southwest Ethiopia. The limitation of the study was most of the discussion part was compared with the qualitative report conduct on high school and university students due to a limited number of articles on youth and qualitative study in our country.

Conclusion and Recommendation

In the study area, Khat, alcohol, cigarette, alcohol, and Shisha or water pipe were the most common substance used. Different factors that drive the youth to engage in substance use were identified and summarized as follows; individual factors, social and economic factors, substance-related factors, and legal and policy factors were the most common factors. Overall, several factors contributed to substance use and could be focused on in health promotion to decrease risky behaviors among youth. Based on the findings of the study, we make the following recommendations: Public health professionals, specifically health promotion and health behavior experts, should focus on providing health education to youth at lower grade level in collaboration with NGO, religious leaders, and educational institutions to avert the substance use prevalence, by proving detail education on the effect of substance use on the health, social life and economy of one country and by developing appropriative IEC and BCC materials. The government should create job opportunities for the youth, encourage different NGOs to invest in youth, and develop recreation centers for youth with different services in order to mitigate the current prevalence of substance use. The government should develop a policy focusing on how and where to use substances, age, place, and time of substance use. It is important to introduce the taxation system on substance use in order to reduce access to the substance. The community, lawyer, and policemen should participate in the implementation and enforcement of rules and regulations on substance use, and also the family should monitor their children and need to act as good role models by avoiding substance use. Further researches are recommended on prevention and solutions to substance use. It is suggested that substance use prevention and cope-up methods should be studied.