What Factors Encourage Young People to Engage in Substance Use? Substance Use and Associated Factors Among Youth in Southwest Ethiopia: A Community-Based Study

Background Substance use indicated the use of psychoactive substances such as alcohol, cigarettes, khat, and illegal drugs. 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 problem among Ethiopian youth mainly in the city of Jimma. Therefore, this study aimed to assess the magnitude of Cigarette smoking, alcohol drinking, khat chewing, and associated factors among the youth of Jimma town in 2019. Methods A community-based cross-sectional study was conducted among youth of Jimma town from March 2019 to April 2019. A simple random sampling technique was used to select 423 study participants. Data were collected using a structured interviewer-administered questionnaire. The collected data were entered into EPI data manager version 4.4.1 and transported to SPSS version 23 for data cleaning and analyses. The disruptive study was carried out to determine the prevalence of cigarette smoking, alcohol consumption, and khat chewing. Binary and multivariable analyses were carried out to identify factories associated with cigarette smoking, alcohol consumption, and khat chewing. Finally, adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine the presence and strength of association. Results The current prevalence of cigarette use, alcohol use, and khat use was 16.0, 30.6, and 45.7%, respectively. Factors associated with current smoking use were substance use by siblings, subjective norm factors, and perceived benefits of substance use. Factors associated with current alcohol consumption were youth who highly perceived substance use as important. Factors associated with current khat use were male, substance use by siblings, out-of-school youth, and subjective norms. Concussion The study findings indicated that the prevalence of khat, alcohol, and cigarettes was high among the youth of the city of Jimma. To reduce the prevalence of khat, alcohol, and cigarettes among youth, coordinated efforts from the youth, the government, health professionals, and the community at large are needed.

zone health bureau identified it as the primary problem among young people, alongside HIV/AIDS. This study also attempted to address a new dimension in that it was a community-based study conducted among a more vulnerable group of youth aged 15 to 25. In Ethiopia, only a few articles on the substance's use on youth at the community level have been published. The finding of this study is useful for counseling and providing health education on the effect of substance use. Additionally, identifying factors associated with substance use among youth at the community level is essential to guide program planning, support youth to adhere to protective issues, and it is also important for the community to increase circumstances for the application of preventive factors and to decrease persuading factors, finally serving as input for policymakers.

Study Design, Period, and Setting
A community-based cross-sectional study was used from March 2019 to April 2019. The study was carried out in Jimma Town. Jimma town is located in Jimma Zone, Oromia Regional, State, and southwest Ethiopia. Jimma was the capital city of the Jimma Zone, and it is found 345 km away from Addis Ababa, the capital city of Ethiopia. The Town has 17 Kebeles with a total population of 205,163 of whom women account for 102,007, male, 103,156, and a total household of 42,742 according to the 2019 Jimma zone health bureau projection population report. Of the total population, around 40,539 (21%) populations are youth (age found [15][16][17][18][19][20][21][22][23][24].

Population
All youth (15-25 years) who lived in the town of Jimma were the source population. All randomly selected youth who lived in the selected Kebeles were considered the study population. All youth (15-25 years old), who lived in Jimma city for more than 6 months and who were present at the house during the data collection period, were included in the study. Young people who were unable to respond due to a severe illness and were not willing to participate in the study were excluded.

Sample Size Determination and Techniques
The sample size was calculated using a single population proportion formula taking the prevalence rate of khat users from the previous study (9). With a 95% confidence level, 5% precision, and a non-response rate of 10 %. The total sample size is 345 * 1.5 design effect * 10% nonresponse rate = 570. A multistage sampling technique was used to recruit study participants. Jimma town was selected purposefully by taking into account the magnitude of substance use (e.g., Khat) in this specific area. Simple random sampling methods were used to select five (30%) out of 17 Kebeles in the Jimma town, namely; Mendera-Kochi, Bacho Bore, Matina Markato, Ginjo Guduru, and Bosa Addis. The number of the household in each Kebele was obtained from the Jimma zone health bureau. The sample size was then assigned in proportion of households in each selected Kebeles (Figure 1). Finally, households were selected using a simple random sampling technique specifically computer-generated random number was used to obtain the required sample size. Household lists were taken from the selected kebele health post office. Their usual place of residence was identified in collaboration with Kebele leaders. For more than one youth present in the households, one youth was selected by using the lottery method, and also for no youth in the household the house was jumped to the next house.

Data Collection Instruments and Procedure
Data were collected using a structured questionnaire. The data collection tool is adapted after reviewing different kinds of literature (9)(10)(11)(12)(13). The data were collected through an intervieweradministered questionnaire on the weekends to include both inschool and out-of-school students. If the youth were not present due to class makeup or other issues during data collection, the data collectors returned to the house at least three times to contact youth who were not present during the first attempt. The data collection questionnaire was developed in English and translated into the locally spoken language (Afan Oromo and Amharic), and then back-translated into English by language experts to check its consistency. The questionnaire was contented with six sections 1, sociodemographic, 2, cigarettes use, alcohol use, Khat use assessing questions 3, factors related to social life 4, subjective norm 5, psychological factors, and 6, factors related to substances. Five health professionals (five diplomas) and one supervisor (one bachelor's degree) participated in data collection. To ensure the quality of data, a pre-test was done before the actual data collection period. About 28 youth (5%) of the sample size households were used for this purpose from nonselected Kebeles (Seto Semero), and some points found on the questionnaire are improved. Before starting a real data collection, supervisors and data collectors were trained for one day about the study's objective, purpose, the ethical issue of the study, and data collection technique.

Dependent Variables
Current khat use, current alcohol use, and current cigarette use.

Independent Variables
Individual-related factor, socio-demographic related factor, substance-related factor, psychological factor, and social-related factor.

Operational and Term Definition
Substance: The commonly used substances, such as alcohol, cigarettes, and khat, induce changes in thinking, feelings, and behavior that can cause dependence. Substance Use: substance uses referred that taking alcohol, cigarettes and khat to alter mood or behavior. Current khat user: a person who chewed   to Forget my problem), with the computed sum score of four items indicating the maximum sum score considered as a psychological factor. Perceived benefit of substance use: considering substances as useful things is measured by the Likert scale, which contains three questions, with the computed sum score of three items indicating the maximum sum score considered as a high benefit of substance use as perceived by the user (13). Substance-related factors: includes substance availability, accessibility, and affordability it is measured by a Likert scale that contains six questions, and the computed score of six items of the Likert scale indicating the maximum sum score is considered as high Substance-related factors.

Data Analysis
The data collected were entered into Epi data manager version 4.4.1 and transferred to SPSS version 21.0 for data analysis purposes. After the data was cleaned for the missing value, the data were analyzed using descriptive and inferential statistics. Specifically, frequency and percentages were used for descriptive analysis, and bivariate and multivariate logistic regression analyzes were used to identify factories associated with cigarette smoking, alcohol consumption, and khat chewing. The degree of dependence (current use of khat, current use of alcohol, and current use of cigarettes) and the independent variable association was assessed using an odds ratio, and statistically significant were declared at 95% of confidence intervals (CI) and the p-value (Pv) less than 0.05. The goodness of the test model was checked by the Hosmer-Lemeshow goodness fit, and the pvalue of the model fitness test was 0.28, 0.31, and 0.42 for cigarette use, alcohol use, and khat use, respectively.

Prevalence of Cigarettes
Ninety-one (16.0%) study participants currently smoked a cigarette and among these, 47.1% of the respondents started

Factors Associated With Current Smoking in Multivariate Logistic Regression
The multivariate logistic regression model identified that the use of sibling substances, the subjective norm factor, and the perceived benefits of substances was significantly associated with current cigarette smoking with a p < 0.05. Respondents whose siblings use substances were identified to be 2.5 times more likely to use cigarettes than those siblings who do not use the substance ( Table 3).

Prevalence of Alcohol
Of the total of participants, 170 (30.0%) reported that they have currently drunk alcohol. Among these, 88 (49.4%) start drinking alcohol at the age of 10-15, and 122 (68.5%) frequently use beer/drink. Of the youth who drank alcohol, 118 (66.3%) reported that they did so under peer pressure and 118 (66.3%) were drinking alcohol to make themselves happier ( Table 4).

Factors Associated With the Current Alcohol Drinker in Multivariate Logistic Regression
The multivariate logistic regression model identified that the perceived benefit of substance use was significantly associated with current alcohol consumption with a p < 0.05. Young people who perceived substance use as important were 72% more likely to drink alcohol [AOR 95% CI 1.715 (1.5-2.03)] ( Table 5).

Prevalence of Khat
The study revealed that about half 259 (45.7%) of the study respondents have currently chewed khat. Amongst these, 140 (52.6%) reported that they start chewing khat at the age of 10-15 years. The majority of 207 (77.8%) of the study participants started chewing khat due to peer pressure. Of the youth who ever chewed khat, 124 (46.6%) used it occasionally and 97 (36.5%) chewed khat for relaxation and entertainment ( Table 6).

Factors Associated With Current Khat Chewing in Multivariate Logistic Regression
The multivariate logistic regression model revealed that sex, substance use by siblings, current school status, subjective norm factor, and psychological factor were significantly associated with the current chewing of khat at p <0.05. In this study, male respondents were eight times more likely to chew khat than female respondents [AOR 95%CI 8.33 (4.24-16.36)]. Respondents whose siblings use substances were 3.6 times more likely to chew khat than those whose siblings

DISCUSSION
This study assessed the prevalence of cigarette smoking, alcohol consumption, and khat chewing and associated factors among youth from Jimma town, Oromia, Ethiopia. This study finding revealed that 91 (16.0%) study participants currently used cigarette and sibling substances, subjective norm factor, and perceived benefit of substances were the main factor associated with cigarette smoking. One hundred and seventy (30.0%) of the study respondents were current consume alcohol and the perceived benefit of substance was the factor associated with current alcohol consumption. The study revealed that about half 259 (45.7%) of the study respondents were current chewed khat and sex, use of sibling substances, current school status, subjective norm factors, and psychological factors were significantly associated with current chewing. of khat. The current prevalence of smoking is 91 (16.0%), slightly higher than the study accompanied in Jimma town 10.2% (14), Bale preparatory school students 5.6% (12), Bonga public college student 1.5% (15), Woreda high school adolescents 6.8% (11), Axum university 9.3%, Ethiopian demographic and health survey report 4.4% (8), Nigerian secondary school student 4.7% (16) and the survey conducted in Sudan 13.7 % (17). This discrepancy occurred due to a difference in study population and study design. The current study was conducted on the youth of Jimma town (including both in-school and out-of-school youth) and also conducted through community-based. The previous study was conducted on in-school youth, and most of the in-school youth waste their time on education when compared with outof-school youth. In the current study, around 43% of the study participants were out-of-school youth. The high rate of cigarette smoking was linked to easy access and availability of cigarettes, as well as the lack of a strong smoking control rule.
The current prevalence of alcohol is 170 (30.0%). This finding is in line with the study conducted on a Mekele university student (18) and it is slightly higher than the study accompanied Bale preparatory school students 23.6% (12), Debre Berhan university student 16.9% (19), Nigerian secondary school 8.9% and conducted in Sudan 2.7 % (16). This discrepancy occurred due to a difference in study population and study design. The current study was conducted on the youth of Jimma town (included both in-school and out-of-school youth) through a community based cross sectional study. The previous study was conducted on university and high school youth. Most of the time, university and high school students were busy due to their educational load when compared to out-of-school youth. In the current study, around half of the participants were out-of-school youth, and they had a lot of free time to drink alcohol. In contrast, this finding was lower than the study conducted on Bonga public college students 44.9 (15) and Woreta high school adolescents 40.9% (11). Low alcohol use might be associated with a high number of Islamic religious followers. In the current study, about 55% of the study participants were Islamic religious followers. The Islamic community considered drinking alcohol as a sin. Therefore, alcohol drinking was not accepted by the community.
The current prevalence of chewing khat is 259 (45.7%). These findings are higher than the study conducted on Jimma university internship medical student 13.4% (20), Jimma town high school students 14.2% (14), Bonga public college student 11.4% (15), Woreta high school adolescents 13.8%, Bale preparatory school students 5.6% (12), Debre Berhan university student 5.7% (19) and Ethiopian Demographic and Health Survey report (8). The current study finding was higher than previous study conducted in different parts of Ethiopia due to difference study population, design and setting. The rational justification for this finding is that khat is readily available, accessible, and affordable in the study area due to the local community's economic reliance on khat tree cultivation and some of the Islamic religious followers' use it for praying, or "duway", but the religion does not command this practice. Also, the community considered khat chewing as normal.
In this study, we identified that the respondents whose siblings use substances were 2.5 times more likely to use cigarettes than those siblings who do not use a substance. This finding is consistent with the previous study (21)(22)(23)(24)(25)(26). This finding could be explained by the fact that young people tend to mimic and exercise what they see their family members do. In this study, the subjective norm factor was significantly associated with current smoking. This study finding is in line with a study conducted on Woreta high school adolescents (11) and Nepal Rithepani high school adolescents (27). And also a study conducted on high school students in north Italy showing that seeing teachers who smoke a cigarette was significantly associated with cigarette smoking (24). This might result from exposure to such behaviors through social and mass media and also due to the government police's weakness in substance use controls.
Our finding indicated that the perceived benefit of substance use was significantly associated with alcohol drinking. Most youths in Ethiopia drink alcohol for relaxation and entertainment purposes and are also considered depressant substances after chewing khat or taking other substances. The study revealed that being male was significantly associated with chewing khat. This finding is in line with the previous study conducted in Ethiopia (14,(28)(29)(30)(31) and also a study conducted in Saudi Arabia (31). It can be argued that the community more accepts substance use among males more easily than females. In this study, the use of the substance by siblings was significantly associated with the current chewing of khat. This finding is in line with previously conducted studies (30,32,33). This finding could be explained by the fact that young people tend to mimic and exercise what they see their family members do.
The youth found out of school was more likely to chew khat than those youth found in school. The possible justification for this finding was an academic failure, lack of a job, and lack of a recreation area were the main factors that motivated youth to use substances. This study revealed that the psychological factor is significantly associated with chewing khat. This finding was consistent with the study conducted on Gonder university students (33). This is due to the strong link between psychological problems and substance use. But the study conducted in Jimma town contradicts this finding, khat chewers are ten times more likely to develop depression than non-chewers (34).
The subjective norm factor of the community was significantly associated with the chewing of khat by youth. This finding is in line with a study conducted on Woreta high school adolescent students (11). The possible justification for this finding is that the community norms favorable to substance use encouraged young people to engage in substance use. The limitation of the study was that most of the discussion part was compared with the study conducted on high school and university students due to a limited number of articles on youth at the community level.

CONCLUSIONS AND RECOMMENDATION
Generally, this study finding indicated that the prevalence of khat, alcohol, and cigarettes was high among the youth of the town of Jimma; specifically, the prevalence of khat was highest among the youth of the Jimma town than the other two substances. Factors associated with smoking were siblings' smoking, subjective norm factors, and perceived benefits of substance users. Alcohol consumption was significantly associated with the perceived benefits of substance users. Khat chewing was significantly associated with sex; siblings' khat chewing of siblings, current youth, school status, subjective norm factors, psychological factors. Therefore, to alleviate these factors, coordinated effort from youth, the government, and the community at large is required. Public health professionals, specifically health promotion and health behavior experts, should focus on providing health education to youth in order to reduce the prevalence of substance use, by providing detailed education on the consequences of substance use on one country's health, social life, and economy. and developing appropriate information education and communication and behavioral change communication materials. Family members or siblings must provide a good example by abstaining from using substances.

DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by Jimma University Ethical Review Board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

AUTHOR CONTRIBUTIONS
TG, DD, and BD were involved in the writing of the manuscript, interpretation of the results, and performed the statistical analysis. TG was involved in the data collection process and study coordination. All authors read and approved the final manuscript.