UNIVERSITY OF GHANA, LEGON COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH FACTORS ASSOCIATED WITH SUBSTANCE USE AMONG SENIOR HIGH SCHOOL STUDENTS ON BUSHROD ISLAND, MONTSERRADO COUNTY, LIBERIA HAWA MARCELIA SHERMAN (10747561) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN APPLIED EPIDEMIOLOGY AND DISEASE CONTROL OCTOBER, 2020 University of Ghana http://ugspace.ug.edu.gh I DECLARATION I, Hawa M Sherman, hereby declare that this Master’s Thesis “Factors Associated with Substance Use Among Senior High School Students on Bushrod Island, Montserrado County, Liberia” is the result of my original research and that no part of it has been presented for another degree in this University or elsewhere. ___________________________ 26/10/2020 Hawa Marcelia Sherman Date MPhil CANDIDATE ____________________________ 26/10/2020 Dr. Adolphina Addo-Lartey Date SUPERVISOR 24/10/2020 Dr. Alexander Manu Date CO- SUPERVISOR University of Ghana http://ugspace.ug.edu.gh II DEDICATION To the memories of all scholars. To My late father Mr. Oliver T. Sherman, my son Mosoka M. Fallah and that special person whose footsteps I followed to reach this far; to the selflessness of all illiterate parents who sacrifice each day to send their children to school. University of Ghana http://ugspace.ug.edu.gh III ACKNOWLEDGMENT My sincere gratitude goes to the efforts of many fine and self-less individuals who were willing to help me succeed in this research work. My supervisor Dr. Adolphina Addo-Lartey, Dr. Alexander Manu and Augustine Boahen. I owe a million thanks to Mr. Demster G. Togba who was very instrumental in responding to my calls whenever I needed his help. Special gratitude goes to Rev. John Garan, Pastor at World of Life Ministries International, and Rev. Othello and Mother Christian Metzger whose prayers and spiritual support have brought me thus far. To my mother Mary Walker-Sherman and Sister Miatta Sherman who had always been there taking care of things. A special one to all my siblings, Alfred, Oliver, and Boakai Sherman. To my nephews and nieces: Othello, Thomas, Josepha, Josephina, Ernest, and little Maliyah. A special one to all my uncles and aunties, and also to my friends and loved ones. Thanks for the love, care and concern. It was not easy, but it was worth it. University of Ghana http://ugspace.ug.edu.gh IV Abstract Introduction World Health Organization defines substance as “a material that alters a person’s mood, perception, or cognitive behavior when it is smoked, injected, swallowed, drunk, inhaled in powder, or vapor”. The use of such psychoactive substances can lead to dependence syndrome which is a thicket of a behavioral, and physiological effect that evolves after sequential use. Methods This study employs a cross-sectional design, using a quantitative approach to gather data on substance use among senior high school students in Bushrod Island, Montserrado county. We adapted the 2012 Global School-based Student Health Survey questionnaire and used it to collect the data through Kobo collect ®(odk) platform. Data was downloaded in Excel 2016, format and analyzed by using Stata version 15 statistical software. The result of the analysis was presented as frequency tables with percentages, and charts. To investigate factors associated with adolescent substance use, cross-tabulations with Pearson's chi-square tests, bivariate and multivariate analyses (logistic regression) were used. Results Of the 402 students surveyed, 291 (72.4%) had ever used a substance before, were males and, those between the ages of 19 to 21 years were 298 (74.1%). Alcohol was the most commonly used substance 255 (87.6%). The majority of students, 332 (83.4%) indicated that they currently used a substance. The age at first time use of a substance was reported as 18 to 20years in 147 (36.9%) University of Ghana http://ugspace.ug.edu.gh V of the students. Risk factors associated with alcohol and drug use include alcohol availability and the only mother as guardian appear to justify the risk of student alcohol and drug use. Conclusion The most used substance was alcohol and the prevalence of substance use among SHS students was high in Liberia. Most of the substances used among SHS students were identified to be alcohol, Marijuana, cocaine, and tobacco (cigarettes), so the results of our data advise that an engagement should be made to cut down the availability of alcohol use. University of Ghana http://ugspace.ug.edu.gh VI Table of Contents DECLARATION ............................................................................................................................. I DEDICATION ................................................................................................................................ II ACKNOWLEDGMENT................................................................................................................III Abstract ......................................................................................................................................... IV Conclusion ................................................................................................................................. IV LIST OF FIGURES ...................................................................................................................... IX LIST OF TABLES ........................................................................................................................ IX LIST OF ACRONYMS ................................................................................................................ XI Definition of Terms...................................................................................................................... XII Operational Definition of substance ......................................................................................... XII Definition of substance use ...................................................................................................... XII Definition of High school students .......................................................................................... XII CHAPTER ONE ..............................................................................................................................1 1.0 INTRODUCTION ..................................................................................................................1 1.1 Problem Statement .................................................................................................................2 1.2 Conceptual Framework ..........................................................................................................3 1.3. Description of the Conceptual Framework ...........................................................................6 1.4. Justification ..........................................................................................................................8 1.5.1 General Objective ............................................................................................................9 1.5.3 Research Questions .............................................................................................................8 CHAPTER TWO ...........................................................................................................................10 2.0 LITERATURE REVIEW .....................................................................................................10 2.2. Types of Substance Use ......................................................................................................10 2.3. Illicit Drugs ........................................................................................................................10 2.4. Prevalence of Alcohol Use ..................................................................................................11 2.5 Prevalence of Tobacco Use ..................................................................................................12 2.6. Cannabis ..............................................................................................................................14 2.7 Cocaine ................................................................................................................................14 University of Ghana http://ugspace.ug.edu.gh VII 2.8. Prevalence of Opioid Use Disorder .....................................................................................15 2.9. Hallucinogens Use Disorder................................................................................................15 2.10. Factors Associated with Substance Use ............................................................................16 2.10.2. Adolescent Employment.............................................................................................16 2.10.3. Psychosocial Factors ...................................................................................................16 CHAPTER THREE .......................................................................................................................22 3.0 METHOD .............................................................................................................................22 3.1 Introduction .........................................................................................................................22 3.3 Study Area ...........................................................................................................................22 3.5. Study Population ................................................................................................................23 3.8. Sampling Procedure ............................................................................................................25 3.9 Inclusion Criteria ..................................................................................................................26 3.11. Data Collection Technique and Tool ................................................................................26 3.13. Ethical Consideration ........................................................................................................27 CHAPTER FOUR ..........................................................................................................................28 4.0 RESULTS.............................................................................................................................28 4.1 Socio-demographic characteristics of participants ...........................................................28 4.2 Socio-economic characteristics of participants ................................................................29 4.3 Prevalence of substance use among students ...................................................................31 4.4 Students knowledge/awareness of substance use by somebody/some people .................32 4.5 Substance usage by students and/or persons known to them ...........................................33 4.6 Reasons for substance use ................................................................................................35 4.7 Effects of substance use on students or persons known to them in the last year ..............36 4.8 Association of socio-demographic characteristics with personal usage of substances among students .......................................................................................................................40 4.9 Association of socio-economic characteristics with usage of substances among students ................................................................................................................................................42 4.10 Association of knowledge on substances with use of substances among students ........44 4.11 Association of knowledge on effects of substance use on persons, family and community with use of substance among students .................................................................47 4.12 Multiple logistic regression analysis for factors associated with substance use among senior high school students .....................................................................................................49 University of Ghana http://ugspace.ug.edu.gh VIII CHAPTER FIVE ..........................................................................................................................58 5.0 Discussion ............................................................................................................................58 5.1 Introduction ......................................................................................................................58 5.2 Prevalence of Substance Use ............................................................................................58 5.3 Commonly used substances ..............................................................................................58 5.4 Factors associated with use of substances ........................................................................59 5.5. Limitations & strengths of the study ...............................................................................61 5.6. Summary ..........................................................................................................................61 Chapter 6 ........................................................................................................................................62 6.0 Conclusion and Recommendation ........................................................................................62 6.1 Conclusion ............................................................................................................................62 6.2 Recommendation ..................................................................................................................63 Government of Liberia ...........................................................................................................63 The Ministry of Education ......................................................................................................63 REFERENCE .................................................................................................................................64 APPENDIXES ...............................................................................................................................71 Appendix I: Assent Form for Participants..................................................................................71 Introduction and consent ........................................................................................................71 Appendix II: Consent Form for Participants ..............................................................................74 Appendix III: Student Questionnaire ........................................................................................74 Appendix IV: Application for Ethical Clarence .........................................................................86 Appendix V: Ethical Clarence....................................................................................................87 Appendix VI: Letter of Support .................................................................................................88 Appendix VII: Introductory Letter .............................................................................................90 University of Ghana http://ugspace.ug.edu.gh IX LIST OF FIGURES Fig1. Conceptual Framework on Substance use .................................................… 4 Fig 2. Shows Reasons for Substance Use among Students in Senior High School ..... 30 Fig 3. Shows Reasons for Substance Use among Students in Senior High School ..... 31 LIST OF TABLES Table 3.1 Enrolment of Schools for the Survey ………………………………………. 22 Table 4.1: Socio-demographic characteristics of participants ………………………… 27 Table 4.2: Socio-economic characteristics of participants ………………………….. 29 Table 4.4: Students knowledge/awareness of substance use by somebody/some people ……………………………………………………………………………. 31 Table 4.5 Substance usage by students and/or persons known to them ………… 33 Table 4.6: Reasons for substance use ………………………………………………. 35 Table 4.7a: Effects of substance use on students or persons known to them in the last year 36 Table 4.7b: Effects of substance use on students or persons known to them in the last year …………………………………………………………………………….…… 38 Table 4.8: Bivariate analysis of socio-demographic characteristics for usage of substances among students ……………………………………………………………………… 40 Table 4.9: Bivariate analysis of socio-economic characteristics for usage of substances among students …………………………………………………………………….… 42 Table 4.10: Bivariate analysis of knowledge on substances for usage of substances…… 44 University of Ghana http://ugspace.ug.edu.gh X Table 4.11: Bivariate analysis of knowledge on effects of substance use on persons, family and community for the use of substance among students………………………….…… 47 Table 4.12a: Multiple logistic regression analysis for factors associated with substance use among students …………………………………………………………….……….. 51 Table 4.12b: Multiple logistic regression analysis for factors associated with substance use among students ………………………………………………………..……………. 52 Table 4.12c: Multiple logistic regression analysis for factors associated with substance use among students ………………………………………………………….…………… 54 Table 4.12d: Multiple logistic regression analysis for factors associated with substance use among students………………………………………………………………….……… 56 University of Ghana http://ugspace.ug.edu.gh XI LIST OF ACRONYMS CVD Cardiovascular Disease HIV Human Immune- Deficiency Virus LSD Lysergic Acid Diethylamide DEA Drug Enforcement Agency PCP Phencyclidine SHS Senior High School STD Sexually Transmitted Disease UN United Nation UNODC United Nations Office on Drugs and Crime WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh XII Definition of Terms Operational Definition of substance A substance is defined as a chemical that modifies a person’s mood, perception, or cognitive behavior when it is smoked, injected, swallowed, drunk, inhaled in powder, or vapor. Generally, substance refers to the use of any drug that affects the mood, mind, and mental processes of a person (World Health Organization, 2014b). Definition of substance use Substance Use: when a person in our study population have ever or currently taken any of the three commonly used psychoactive substance: alcohol, cigarette and or marijuana. Definition of High school students High school is the next step up from primary school and includes grades 10 through 12. A person generally starts high school at age 14 or 15 and finishes at age 18. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 INTRODUCTION A substance is defined as “a chemical that modifies a person’s mood, perception, or cognitive behavior when it is injected, smoked, swallowed, drunk, inhaled in powder or vapor” (World Health Organization 2014) Generally, substance refers to the use of any drug that affects the mood, mind, and mental processes of a person (World Health Organization, 2014b). The use of a mind-expanding substances can lead to addiction syndrome which is a thicket of a behavioral and physiological effect that acquire after sequence utilization (World Health Organization, 2017). The use of a substance such as illicit drugs, cigarettes, and alcohol has become a worldwide health issue because of an increase in their use especially in developing countries (Birhanu, Bisetegn, &Woldeyohannes, 2014). A research was conducted among Senior high school students in Nigeria which reported that the Current substance user was 69.2% with multiple substance use being 57.4% and lifetime prevalence of substance use as 87.3% (Oshodi et al 2010). Substance use was found to be 69.8% rate of lifetime prevalence among college students in Kenya (Atwoli et al 2011). In Ethiopia, the commonly used substances were cigarettes, alcohol, and cannabis which often lead to addiction (Kebede 2005). Senior High School Students' frequency of use of substances has become a serious public health problem that needs global attention. The major substances used worldwide by students are cannabis, marijuana, opioids, amphetamines, alcohol, and now tramadol. This behavior calls for a collaborative action since the world psychoactive substance use is approximately, 1.3 billion smokers, 185 million illicit drug users, and 2 billion alcohol abusers, (World Health Organization, 2018). University of Ghana http://ugspace.ug.edu.gh 2 In 2011, a cross-sectional study was conducted in the Liberian capital, Monrovia to assess the ratio of substance use among secondary school students (Cheng, 2009). The study findings showed that 51% of students reported using alcohol and 9% of students reported using marijuana (Harris et al., 2011). Substance use is also believed to contribute to interpersonal violence and sexual risk-taking in Liberia. It has been cited as one of the key factors contributing to physical and sexual violence and crime in Liberia today (Fuerth, 2011). With the higher percentage of symptoms amongst Liberia people, it is mostly like that substances will increase. According to Liberia: Social and Economic Impact of Illicit Drugs (LSEIID), (2016), “between 1990 and 2003, many children were conscripted and regularly drugged to fight wars for various factions. Fighting forces in the multidimensional Liberian civil war were dominantly children forcefully conscripted and drugged to engage into unconventional warfare.” It is most likely that children who had joined this event were children whose parents. The risk factor of substance abuse in Liberia seems to keep increasing, mainly amongst the youths and young faults population. Research conducted in Kenya showed that high school students’ use of a substance such as tobacco, and alcohol is associated with peer pressure, poor academic performance, and a family chronicle of alcohol and drug use (Peltzer et al., 2011). The use of harmful substances leads to low academic achievement, other sexually transmitted infections (STIs), high risk of HIV infection, and or psychiatric disorders such as depressive symptoms, sleeplessness, hopelessness, and lethargy, (Birhanu et al., 2014). University of Ghana http://ugspace.ug.edu.gh 3 1.1 Problem Statement Substance use is a threat to well-being, health, and security, as well as safety and sustainable development (OSEWA 2017). Currently, substance use is a global problem and adolescents are the primary victims of these circumstances (UNODC 2013). Liberia has a population of 4,689,021 with children from 15 to 24 years representing about 917,092, male (457,806), and female (459,286) accounting for 19.56%. Substance use among young people, especially SHS students, is on the increase; this was reported by Gerald C. Koinyeneh, (gerald.koinyeneh(@frontpageafricaonline.com) in Liberia. Several local experts have suggested that substance abuse is one of the key issues affecting the health and well-being of Liberian youth (Ezard et al., 2011). In Aug 2019, a retrospective study on Common Mental Health Disorders 2015 - 2018 was conducted with 600 patients admitted at E. S. Grant Mental Health Hospital, the only mental health referral hospital currently in Liberia. The study finding shows that of the 600 records reviewed, 56.8% were males. The mean age was 32 (±7) years; the commonest age group was 20-24 years (19.7%) and never married (72.1%). Students were 17%. Commonest mental disorders were SUD (35%), mood disorders (29.3%), psychosis (23.5%) and schizophrenia (4.3%). SUD is more common among those aged less than 30 years (51.7%). %), especially students. However, among those aged 30 years and above, mood disorders (74. 4%) and psychosis (47.5%) are common. Compared to those that never married, mood disorders are common among the married people (51.5%) to (22.6%) in those that never married. (Dwalu et al, 2019) an unpublished research work. In 2011, a cross-sectional study was conducted in greater and central Monrovia to explore the ratio of substance use among senior school students (Cheng, 2009). University of Ghana http://ugspace.ug.edu.gh mailto:(@frontpageafricaonline.com) 4 The research findings showed that 51% of students reported using alcohol and 9% of students reported using marijuana, respectively (Harris et al., 2011). Substance use is also believed to contribute to interpersonal violence and sexual risk-taking in Liberia. Substance use is not well understood in Liberia. The lack of current and culturally-specific information about substance use makes it difficult to conduct meaningful research on this issue and develop policies and interventions to serve affected populations(Prust et al., 2018). Risk factors that contribute to premature deaths globally include but not limited to tobacco, alcohol and use of other psy- choactive substances (e.g., marijuana, amphetamines). It is important to identify factors that put adolescents at risk to developing problematic substance use. Studies that have examined risk factors of substance use in adolescents have focused on factors at the individual and interpersonal levels. (Ozeylem et al., 2021) Failure to identify these factors will lead to a display of difficulty, poor peer relationships, health-related problems, social violence, unsafe sex, academic difficulties, and involvement with the juvenile justice system. Also, there are effects for family members, communities, and the entire society. Some factors influencing the use of the substance are socio-economic and accentuated by peer pressure (Lippit, 2013). There is a need to identify risk factors and consequences of usage of substance to inform authorities to enforce the law. University of Ghana http://ugspace.ug.edu.gh 5 1.2 Conceptual Framework Family domain A family record in substance use Sibling uses of a substance Poor family supervision Lack of parental relationship Sibling use of a substance Poor family supervision Lack of parental relationship Abuse Physically abuse Sexually abuse School domain Achievement Self – Concept Self – acceptance Self – confidence Substance use Alcohol use Tobacco use Illicit drug use Substance Use Individual/ Peer domain Friends use of a substance Peer reward for anti-social Peer reward for anti-social Belief in Substance Perception Self – efficacy Demography Age Sex Economic Status University of Ghana http://ugspace.ug.edu.gh 6 Figure 1: Conceptual framework 1.2.1 Description of the Conceptual Framework The model was constructed to explain the incessantly increasing substance use disorder among school-going children. Based on the build model, the belief of substance use had important and straight effects in influencing high school students' use of the substance. However, other factors indirectly affected substance use. Those like self-concept, family environment, satisfaction with school life, social support, and personality vulnerability (Bae & Rosel,2009). There are so many factors that influence the use of substance among SHS students, most of which are outlined in figure 1 which is the framework. Substance use is the outcome of why the others such as family domain, school domain, and individual/peer domain are the independent variables. Family-level domain factors which include the history of the use of a substance within the family, school-going children use of the substance is directly associated with the following; sibling use of a substance, poor parental supervision, and poor parental relationship. The home is where every child gets his/her first idea from which is the way to approach things, so whatever they see while growing up, be it good or bad, will become part of them. Also, since most of the school-going children are adolescents which means the area in the developmental stage, they could easily be attracted to things around them, be it right or wrong so those behaviors also influence them to want to experiment happenings around them. All the same, the use of substance among parents and siblings can also influence adolescents to become substance users. Parents and older siblings are most times seen asmodels, so children will always want to do things to be like their parents. Note that some parents and older siblings will have no worries to send their younger ones to get/buy substance for them. They will show the young ones the location where it is being sold and wouldn't mind taking it in the presence of the children, not considering the effect of their actions. At the same time, they will give the University of Ghana http://ugspace.ug.edu.gh 7 younger ones substance like alcohol to take in a small amounts. Parenting is a very important factor in a child's upbringing. The relationship between the child and the parents to a very large extent will determine the behavior pattern of the child; i.e whether he will be wayward or respectful. When parents let “loose” of their child such as freedom of movement irrespective of the time of day, the child picks up certain behavior including substance use which if not checked leads to substance misuse. Most SHS students who belong to families of substance users are physically and sexually abused by their parents and older siblings. These students are victimized by their family members and warned never to disclose it to anyone. These students go through depression and become impulsive and anti-social and so to overcome such challenges they turn to substance use as an option of relief. Moreover, most Senior High School students use all manner of methods to study. For those who are not pulling their way through academically, they are being advised to indulge in substance use. One of the most popular substances widely used on campuses is ‘wee’ (marijuana). It is thought to help students stay awake to learn for long hours and even give better understanding when studying difficult subjects. So, academic achievement contributes to some extent to substance use among SHS Students. They do all these because they want to raise their self-esteem. SHS students who are always bullied and timid in school turn to indulge in this act just to have self-confidence and be accepted by the so-called “hardcore” students in the school. For others, substance use is due to peer-influence. Students whose friends use the substance, invariably tend to try it to be accepted by the group and to avoid mockery from friends. Peers who give recognition to anti-social behaviors tend to influence their friends to take in substance to make them look wild and confident. University of Ghana http://ugspace.ug.edu.gh 8 1.3 Justification The outcome from the study on the prevalence of the use of substance among senior high schools students on the Bushrod Island will inform policymakers in Liberian education system to adopt policies that will be pertinent to the students in terms of their mental and psychological health. The information collected from the study will help students who go through challenges like psychological problem be able to receive help from trained personnel so as to not get involved in substance use. Policymakers will work to strengthen and restructure the educational system by providing Student Psychologist in senior high schools or the country at large, and will also adopt policies when necessary and to improve the parent and teacher relationship. The result from the study factors associated with substance use will serve as a baseline for other researchers who will embark on future research in substance use. 1.4. Research Questions To address the study objectives, the following questions were asked: 1. To what extent do senior high school students on the Bushrod Island use substances? 2. What type of substances do senior high school students on Bushrod Island commonly use? 3. What are those factors that are associated with the use of substance among senior school students on the Bushrod Island? University of Ghana http://ugspace.ug.edu.gh 9 1.4.1 Study Objectives 1.4.2 General Objective To assess substance use and associated factors among SHS students on the Bushrod Island. 1.4.3 Specific Objectives 1. 1. To assess the prevalence of the use of substance among SHS students on Bushrod Island. 2. To assess the types of substances commonly used among SHS students on Bushrod Island. 3. To determine the socio-demographic and economic factors associated with use of substance among senior high school students on Bushrod Island. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO 2.0 Literature Review This chapter looks at the relevant literature on the use of mind-expanding substances, considering the specific types often used and current use, and those factors related to their use. 2.1 Types of Substance Use Worldwide, some of the most commonly used psychoactive substance, according to the WHO, include alcohol, tobacco, marijuana, and prescription medications. From the Monitoring future, over-the-counter medications and prescription reports for the absolute majority of the drugs are most commonly misused by senior high school students. Tramadol has taken the lead in many countries, including Egypt, Ghana, Nigeria, and Liberia. In Liberia, it has become the new normal among senior high school children and this is usually done on Friday which is referred to as Super Friday. 2.2 Illicit Drugs According to the WHO, whether a drug is licit and illicit depends on its production, possession, or trafficking. It, therefore, proceeds to define an illicit drug as harmful substances that are produced, trade, and/or consumed illegally. (World Health Organization, 2019). These harmful substances are mention as either “narcotic or psychotropic substances” this depends on the schedule under which the international convention has been placed (Čepas & Risimović, 2019) University of Ghana http://ugspace.ug.edu.gh 11 Drug use and disorders, with related health conditions, are a leading worldwide public health threat especially to children, young people, and their families (World Health Organisation, 2019). Combined figures on the use of illicit drugs are staggering. WHO reports that in the year 2010 alone, 148 countries, reported the use of inject-able drugs. Of these, 1 in 20 adults, or 230 million people, are estimated to have used an illicit drug at least once, and 120 persons among those who use inject-able illicit drugs were reported to have HIV. An estimated minimum of 15.3 million persons has drug use disorders. And the cost in the management of the use of the illicit drug is no less disturbing in that close to 2 beds per 100 000 population are accessible for the treatment of alcohol and substance use disorders (WHO, 2018). According to the 2015 report by the UNODC, West Africa ranks high in production, use, and a transshipment region of illicit drugs. Africa remains a transshipment region for cocaine traffic to Europe and Ghana reported impounding 901 kg of it. Among the most widely used illicit drugs on the global scale are cannabis, opioids, amphetamine‐type stimulants (ATS), and cocaine. In Liberia, these and recently tramadol, are prevalent (World Health Organisation, 2015). 2.3 Prevalence of Alcohol Use Alcohol use is, another psychoactive substance with dependence- producing properties (World Health Organization, 2014b) is only about half as harmful as tobacco. A report from Global Information Systems on Alcohol and Health (GISAH) explains that alcohol consumption kills 3.3 million annually. Moreover, alcohol accounts for 5.1% of the global burden of diseases and plays a causal role in 60 diseases or more than 200 health conditions in the world (World Health Organization, 2014b). The WHO estimates that out of the world population 38.3% of them consumes alcohol and whereas persons aged at least 15 years consume 6.2 liters of pure alcohol annually, and those who consume alcohol consume an average of 17 liters pure alcohol per year. According to global estimates in 2010, the average University of Ghana http://ugspace.ug.edu.gh 12 consumption of pure alcohol per person age 15 years or older was 13.5 grams or 6.2 liters of pure alcohol (World Health Organization, 2014b). According to WHO, half of the recorded alcohol consumed is in the form of spirits. Of the total daily alcohol consumption, about a quarter 24.8% is unrecorded or produced and sold outside normal government controls. Whereas 61.7% had not consumed in the past 12 months, drinkers who engaged in heavy episodic drinking account for 16%. The highest alcohol consumption per capita can be found in the WHO EU Regions and the Americas (World Health Organization, 2014b). An increase in alcohol consumption among high school students has contributed to approximately 4% of the global burden of disease. Alcohol consumption comes with its consequence, mostly associated with poorer outcomes from an infectious disease for heavy drinkers (Jürgen Rehm, 2010). Alcohol can be classified into different types and according to the (WHO) report, people aged 15 and above in Ethiopia consume 33% of beer, 22% of spirits, others 43%, and 2% wine (World Health Organization, 2011). 2.4 Prevalence of Tobacco Use According to the World Health Organization, tobacco use has attained an epidemic dimension, affectation is among the biggest public health threats that the world is faced with. Related tobacco diseases kill more than 7 million people annually compared with malaria, HIV/AIDS, and tuberculosis combined (WHO, 2017). The World Health Organization reports that from a nationally representatives sample of students aged 13-15 years, the Global School-Based Student Health Survey 2012 revealed that the prevalence of cigarette smoking (whether daily or not) at the time of the survey among students was 8.3% (with males reporting for 9.2% and females 7.1% respectively). The 2013 LDHS national survey shows that in Liberia prevalence of cigarette smoking among secondary University of Ghana http://ugspace.ug.edu.gh 13 high school students7% of males and 0.3% of females (aged 15-49 years) use tobacco on a daily and non-daily basis any form of tobacco (including cigarettes, cigars, a pipe, snuff, shisha, water-pipe, etc). The specific use of cigarettes was common in male and not in female:5.8% of males and 0.1% of females were current users of tobacco and any form of cigarettes including manufactured and roll-your-own at the time of the survey. The rates for smokeless use of tobacco (including chewing, sniffing, or placing the product in the cheek) for the same age group are available in the 2013 LDHS; and are for both males and females were respectively 0.5% and 0.1% the survey was conducted. The age-standardized prevalence estimates (with lower credible and upper credible intervals) for daily tobacco smoking among persons in the country for persons at least 15 years of age is 18.3 (13.8 and 10.9)%; 13.8 (9.0 and 1.1)% for males, and 1.6 (1.2 and 0.4)% for females ( Report from WHO on the global tobacco epidemic, 2017). The Liberia Demographic and Health Survey, 9.6% (396 out of 4,118) of men aged 15 to 49 years reported smoking cigarettes or pipe or tobacco. Of the 4118, 2,383 were of high school going age (15-19 years) and 5.8% of those in this category smoked tobacco (Liberia Demographic Health and Survey, 2013a). Alternatively, of being on track to achieving a 30% comparative reduction in tobacco use among persons 15 years of age and older by 2025, the survey data showed that only a 14% reduction in prevalence rates would result from efforts made to date. The progress from the report shows that their global level countries are on track to achieve a 22% reduction by 2025. All the same, the voluntary global target is still short of a 30% reduction between 2010–2025 (WHO global Report in trends prevalence tobacco smoking). A study conducted in Kenya by Peltzer et al revealed that 69.8% of college students are victims of cigarette smoking (Peltzer et al., 2011). At the moment, the increase of tobacco use is growing at a fast rate among students in high schools in most countries but in Liberia, its University of Ghana http://ugspace.ug.edu.gh 14 uses have not decreased even due to its ban on television and radio advertisement (Liberia Step Survey Report 2011.docx). 2.5 Cannabis use Following the WHO usage of the term, cannabis refers to marijuana or hemp. The use of cannabis appears to have remained high at least from 2012 to 2013. The estimated prevalence of the use of this substance in 2012 was about 162 million to 324 million people worldwide (World Health Organisation, 2015). That is about 3.5% and 7% of the world’s population. According to the UNODC report, aged 15 – 64 years in the world used cannabis non-medically, accounting for approximately181.8 million people in 2013, making this substance the most globally commonly used psychoactive substance under international control (United Nation Office on Drugs and Crime, 2015). A research found that an estimated 22.2 million Americans aged 12 and above were current users of marijuana (Mangerud et. al,2014) This figure might be increasing considering the increasing demand for treatment for disorders related to the substance and associated health conditions in high- and middle-income countries (World Health Organization, 2016b). Moreover, Banys revealed that cannabis is an attractive option for users it has a relatively low cost, it can be accessed easily, reduced risk of overdose, and sensed a low risk of harm (Banys, 2013). Evidence shows that students who use marijuana have impaired short-term memory and judgment, and distorted perception resulting in poor academic performance. Also since the brain systems of young people are still maturing, regular use may have a long-lasting and negative effect on their cognitive development (Volkow, 2017). University of Ghana http://ugspace.ug.edu.gh 15 Marijuana use comes with its consequences such as increases risk of a chronic cough, bronchitis, addiction, increases the risk of schizophrenia in vulnerable individuals, and depression, may increase the risk of anxiety, and a motivational syndrome (Volkow, 2011). 2.6 Cocaine use The United Nations Office on Drugs and Crime 2015, Reported the prevalence of cocaine use in Southern, West, and Central Africa was high, i.e., 0.7% in 2013. Africa remains a transshipment region for cocaine traffic to Europe and Ghana reported an impounding 901 kg of it (United Nations Office on Drugs and Crime, 2015). 2.7 Prevalence of Opioid Use Disorder Opioids are a category of drugs that include the following illicit drug heroin as well as the licit pain relievers prescription morphine, codeine, hydrocodone, oxycodone, fentanyl, and others (Authority, 2005). Global trends in the estimated number of drug users from 2009 to 2014 indicate that the use of opioids, opium, heroin, including the use of nonmedical pharmaceutical opioids, has stabilized at high levels (United Nations Office on Drugs and Crime, 2015). In 2015 it was estimated that 20.5 million American children age 12 or above suffer from substance use disorder, and 2 million involves in pain relievers prescription while 591,000 involve heroin (SAMHSA, 2016). Risky sexual behavior and Unsterile injecting practices among users of opioid is a major contributor to the spread of HIV, hepatitis, and other infections (Fischer B et al, 2017). This study focused on tramadol which belongs to the opioid family it is an analgesic with a multimode of action, it is used for treating both acute and chronic pain of moderate to severe intensity. Clinically tramadol is considered to be a safe analgesic but one can show the physical dependency of the opioid type when used for a sustained period (World Health Organisation, 2017). Recently tramadol has become a public health problem due to its University of Ghana http://ugspace.ug.edu.gh 16 abuse especially, among adolescents. According to a study conducted among college schools in Iran, 12.5% of the students abuse tramadol (Bashirian, Barati, & Fathi, 2017). This calls for public health intervention since it can result in fatal intoxication. Abuse of tramadol can cause central nervous system depression, coma, and seizure (World Health Organisation, 2017). 2.8 Hallucinogens Use Disorder Hallucinogens are a group of drugs that can cause hallucinations thus profound distortions in a person’s perceptions of reality. Hallucinogens are man-made can be found in mushrooms and some plants (or their extracts). They are usually divided into two broad categories: classic hallucinogens (such as LSD) and dis-associative drugs (such as PCP). Consequences of the use of hallucinogens are swings intense emotional and hearing sounds, seeing images, and feeling sensations that seem real but are not (Authority, 2015). 2.9 Factors Associated with Substance Use 2.9.1 Demographic Factors Some demographic background characteristics have been found risky for substance use. These include age, sex, race, and economic status (Peltzer et al., 2011). The role of sex in the consumption of alcohol is manifested in the recorded and unrecorded per capita average consumption between 2008 and 2010 in that the total average consumption was 7.8 liters and 1.9 liters for males and females. In the year 2010 alone the total capital per alcohol consumption among drinkers aged 15 or older was 23.6 liters and 13.9 liters of pure alcohol among males and females respectively (World Health Organization, 2014a). 2.9.2 Socio-economic factors: Adolescent Employment One other factor whose effect on substance use among adolescents has been debated over a long time is their employment. Whereas some initially thought that employment was positive for adolescent development (Hamilton & Crouter, 1980), some have thought that employment University of Ghana http://ugspace.ug.edu.gh 17 by adolescents is a poor academic achievement (Steitz & Owen, 1992). The Organization between substance misuse behaviors and employment among 4800 public high school black and white school-going children, (Valois and colleagues,1999) established that young people who work more than 15hours a week at a job for earnings during high school have a higher risk for misuse of substance and the resultant effects (Jackson, Waller, & Ph, 1999). 2.9.3 Psychosocial Factors 2.9.3.1. Relationship with Adults One of the factors associated with substance use among second high school students cycle is their relationship with adults. Relationship with adults is defined in terms of children's self- disclosure, parental support, bonding with parents, parent-initiated monitoring of adolescent behavior, and relationships with school personnel. This relationship is either protective or risky for the use of psychoactive substances. An Adult relationship, defined in terms of children's bonding with parents, can have a double edged-sword effect on adolescent substance use. Whether it is protective against or risky for substance use among adolescents depends on whether the parents are themselves users of psychoactive substances. In a longitudinal study to examine the relationship between parent illicit drug use and bonding to parents as predictors of substance use in children in 150 heads of families by drug abusers in method one treatment for addiction of opiate, Fleming and colleagues observed that bonding to parents was moderately negatively correlated with drug use in children whose parents had stopped using psychoactive substances. Linda Ryan and colleagues examined the protective effects of four adult relationships (parental support, self-disclosure to parents, adolescent behavior, parent-initiated monitoring, and relationships with school personnel), on three critical problems of adolescents: The use of substance among other problematic outcomes using an ethnically diverse adolescent in an University of Ghana http://ugspace.ug.edu.gh 18 economically disadvantaged urban area in the southwestern United States. Investigators reported protective roles of four adult relationships against substance use (Ryan, Miller-loessi, &Nieri, 2007) In a study of 1800 school-going Black, colored, and White adolescents the family predictors ( parental monitoring/knowledge and limit setting, parental behavioral control, marital relations and stress of family) of adolescent substance use, Amoateng et al found that the rate of substance use was higher among adolescents were foretold by parental behavioral parental monitoring/knowledge, control, limit setting, marital relations, and family stress (Amoateng, Barber,& Erickson, 2009). Relationship with adults is defined in terms of relations with significant adults at school and the family. Within the family, it has been reported that adolescents receiving parental support and encouragement have been noted to protect adolescents against the use of psychoactive substances (Crosnoe, Erickson, & DornBusch, 2002). However, investigators debate on the effectiveness of parental monitoring and restriction (Crosnoe et al., 2002). Communication with parents in terms of both parental initiated communication and adolescent self-disclosure of parents are protective factors against substance use. One reason is that having discussions helps adolescents identify what issues that could be detrimental. Aside from feeling obliged to please a listening parent through communication, self-disclosure helps parents to know what is happening in the lives of their adolescents (Kerr & Stattin, 2015). In a study of 9th to 12th graders to find out the prevalence and correlates of substance misuse in the past year in Northern New Jersey, Chen et al found that substance abuse was higher among males than female students. However, after controlling for covariates, the prevalence of substance abuse was higher among females than males (Chen et al, 2004). University of Ghana http://ugspace.ug.edu.gh 19 2.9.4 Psychological factors Studies from neuroscience have associated risky behaviors occurring in adolescents with changes in brain networks involved in motivation and reward processing. This involves a network in the brain that is mainly responsible for reward processing. Evidence shows that the stratum dopamine circuit, a key node in this network, changes drastically in adolescence than in childhood or adulthood. Brain patterns show that adolescents have a greater desire for rewards and experience more pleasure when receiving rewards than do children and adults. The role of this network as expressed insensitivity to rewards and punishment is not very clear with regards to drug use including other risky behaviors characteristic of adolescents. Whereas some studies indicate that school-going children who exhibit reward higher sensitivity and punishment lower sensitivity are more prone to substance use, others think that the characteristic of high reward sensitivity confers benefits. In a study to examine the association between sensitivity reward and misuse of substance in middle school children and 216 senior high school students, Jeremy Genovese and Deborah Wallace established a positive relationship between a high reward and low punishment sensitivities and substance abuse (Genovese & Wallace, 2010). Anxiety has been found to increase the risk for substance use, and the use of substances has also been found to increase the risk for anxiety (Kushner G, Abram B, & Carrier, 2000). These feelings may lead to problems related to the high use of the substance, the use of substances is found to reinforcing by people (it minimize uncomfortable feelings) and hence maximize the occurrence and quantity of their use Marmorstein, White, Loeber, & Stouthamer-loeber, 2010). Marmorstein et al (2010) examined generalized and social anxiousness as a predictor of age at first substances use and progression to the use of substance problems among boys. The study found that generalized anxiety, a "persistent and excessive worry about several different University of Ghana http://ugspace.ug.edu.gh 20 things"1, and social anxiety (shyness and withdrawal) strongly predicted the age of first use of alcohol and tobacco than for marijuana use. It was also found that both generalized and social anxiety predicted risk for the development of marijuana problems but not alcohol or tobacco problems. Factors that explain the prevalence of consumption of alcohol on a population level include socio-demographic factors, level of economic development, prevalence rates of self-discipline, preferred beverage types, and culture. 2.10 Illicit Drug Use Report from WHO on the health and social effects of nonmedical use of cannabis categorized associated risk factors with illicit drug use or source of those factors as the community/society; the school and peers; the family; the individual and the media. Risk factors under the community or society include laws and norms that favor drug use, availability of drugs, and access to drugs, extreme poverty, and anti-social behavior in childhood. Risk factors which are more common among adolescence fall under the school/education and peers and include poor academic achievement, low commitment to school, and peer group attitudes towards substance. The media poses a risk for illicit drug usage by advertising norms that are favorable towards drug use (World Health Organization, 2014a). In the case of the use of an illicit drug, the WHO suspects the harm and protective factors associated with nonmedical cannabis use as well as other drugs are similar for high-income and developing countries, though further studies are needed for confirmation. In developing countries, the risk of increase factors onset of the use of cannabis includes easy access to substance, alcohol, and tobacco use at an early age, and social norms that are tolerant of drug use and alcohol. The use of illicit drugs is common among specific subgroups and party settings (World Health Organization, 2014a). University of Ghana http://ugspace.ug.edu.gh 21 2.11 Summary It was also found that some socio-demographic factors, familial factors such as relationship to adults in the family, and psychological factors, are associated with the use of psychoactive substances. However, it has been found that some of these factors, singularly or a combination with others, determine the use of substances more than they do for others in specific contexts. University of Ghana http://ugspace.ug.edu.gh 22 CHAPTER THREE 3.0 METHOD 3.1 Introduction In this chapter, we describe those methods that were used in the research. It includes design, study location, variables, study population, sampling methods, sampling size, data collection technique, data collection methods and tools, data processing, and ethical consideration. 3.2 Study Design The research utilizes a cross-sectional descriptive design using a quantitative approach to gather data on substance use from senior high school students in Bushrod Island Montserrado county. 3.3 Study Area The study area is Bushrod Island which encompasses three districts and is part of Montserrado county. There are forty-five schools on the Bushrod Island out of which are nine senior high schools in the three districts. The study consist of students of the three which were randomly selected for the study. 3.4 Study Variables The dependent variable was substance use. The independent variables were socio-demographic characteristics, family domain (parents’ use of the substance, sibling use of the substance and parental monitoring), school domain (awareness of substance use by students), community domain (physical and sexual abuse,) and individual domain (friends’ use of substance). All of the independent variables will be measured directly from the questionnaire. University of Ghana http://ugspace.ug.edu.gh 23 3.5 Study Population The population of the study is students of senior high school on Bushrod Island who were selected during the period of data collection. The study targeted a total population of 3993 students from three different schools on the Bushrod Island. The targeted students were at 10th- 12th grades and where so selected to give a broad picture of factors that are associated with the use of substance among senior high school students. All students who attended the school were both males and females ages above 16 years. 3.6 Sample Size Determination In a research conducted by Harris et al (2012), the prevalence of the use of substance among senior school students in Liberia, alcohol was the most commonly used substance in the study sample, and participants 18 years and younger accounted for 44.5% of those who had consumed alcohol at least once. This was followed by marijuana as the second prevalent substance used; with 9% who reported using it at least once. There has not been any study online that is in connection with the use of substance among students in the senior-high schools on Bushrod Island. Therefore, using the proportion of students who used substance from Harris’s study, then the minimum sample size required for this study was calculated using the formula by Cochran (1977) as follows: n= z2 *p *q/d² Where: n= desired sample size z= standard deviation at 95% confidence interval (standard value = 1.96) p= estimated proportion who use substance q= proportion who do not use substance = 1-p d= margin of error Moreover, a 5% precision was assumed. Thus, substituting these parameters in the formula, University of Ghana http://ugspace.ug.edu.gh 24 the sample size was computed as follows: n = 1.962 * 0.49 * 0.51 0.05 = 384 An upward adjustment of the sample size was carryout and 5% non-response rate was calculated resulting in a final sample size of 402. 3.7 Sampling Methods Three schools were selected randomly from a total of nine senior high schools on the Bushrod Island by balloting process. An appropriate sampling technique was put in place to determine the sample size for the selected schools. From the estimated minimum sample size, the proportion of students for each school was determined as shown in Table 3.1 Table 3.1 Enrolment of Schools for the Survey Name of school Total enrollment Computed sample size School 1 1625 164 School 2 942 95 School 3 1426 143 Total 3993 402 A systematic random sampling procedure was employed to select respondents from each school to select the samples, we calculated the total number of students required from each school (based on their total population using sample proportional to size). We also calculated the sampling interval wherein the total number of students from each school was divided by the required sample from of each school. So then the sampling interval was calculated where we used the number between one (1) and nine (9) as our starting point and a skip interval of eight (8) was used. The study sample recruited students from 10th to 12th grades in each selected school. We also asked for the class register and select the required number of students for the study and the required number University of Ghana http://ugspace.ug.edu.gh 25 of students was selected by systematic random sampling. 3.8. Sampling Procedure A 3-stage random and systematic sampling procedure with probability proportional to size 1 was used to select respondents as follows: the first stage involved a random selection of three schools. A balloting approach was carryout to select three (3) out of nine (9) schools. The number of students in each school was the measure of size. The second stage was made of a selection of classes in each school. Each class has the same characteristics; hence, a random sampling was used to select the various classes from 10th grades to 12th grades. The third stage involved a systematic selection of participants from the classes using the class register. Firstly, the total number of participants from each school was calculated. For ethical reasons the name of the schools is not disclosed, therefore each school was represented with a number as shown in Table 3.1. In the selection of participants from each class, systematic sampling was used. Thus, if the total number of students in 10th grade is 400 and the total sample size for each class was 57 then, 400 57 = 7 In order to have the desired sample size as a benchmark, a random sampling was used again to select the 1st to the 9th students and if the 2nd person was selected as the first respondent, then the second respondent will be the 9th respondent. We involved proportional stratified random sample to select all participants by sex, age group, number of people in stratum and strata sample size. University of Ghana http://ugspace.ug.edu.gh 26 3.9 Inclusion Criteria All students in the selected senior high schools on Bushrod Island who will enroll during the period of the research will be eligible. 3.9.1 Exclusion Criteria All senior high school students enrolled in the selected schools during our research period but who were absent during the time of the interview. 3.10 Quality Control The following activities were undertaken to ensure the quality of data collected; Two research assistants were recruited and provided one-day training on the purpose of the study, study objectives, method of sampling, data collection technique, and ethical consideration. The training session for research assistants covered in detail the protocols, techniques, and courtesies to be observed during interviews and the process for obtaining informed consent form study participants. Research assistants were taken through all the questions that were administered and were allowed to clarify issues pertaining to the questions that were not clear to them. Questions were numbered, coded, sorted out, and kept in files that were labeled with the names of the three schools within the study. The questionnaire was reviewed by the academic supervisor and data collected was cross-checked daily for accuracy and completeness before sending data to ensure validity and reliability. 3.11 Data Collection Technique and Tool A structured questionnaire was adapted from the 2012 Global School-based Student Health Survey (GSHS). The questionnaire was modified to reflect the study objectives and was used to obtain quantitative data from the students in the three selected schools on Bushrod Island. The questionnaire was made up of a close-ended question with a response set to each question. The questionnaire was in three sections comprising of socio-demographical characteristics, types of a substance commonly use (knowledge on substances use, types of substance use, University of Ghana http://ugspace.ug.edu.gh 27 reasons for the use of the substance and the effects of the use), factors associated with the use of substance and prevalence of substance use. The questionnaire was developed and built in the Kobo collect platform. The questionnaire was administered from the kobo collect platform using a gadget. The questionnaire was self–administered. The research helper assisted students who found it difficult to answer the questions. 3.12 Data Processing and Analysis A structured questionnaire was used to collect the data through Kobo collect ®(odk) platform, data were downloaded and analyzed by using Stata version 15. During the preparation of the questionnaire, a code was given to each answer of a question to facilitate data entry into Stata version 15. Data cleaning was done, the frequencies of responses were generated categorically variables such as social-demographic characteristics are described in frequencies, and percentages in a table. The results of the analysis were presented in a frequency table and charts. To investigate the factors associated with adolescent substance use, Pearson’s chi-square, tabulations, bivariate and multivariate analyses of logistic regression were used. The significance level of 5 was used as cutoff hence, all p-values less than 0.05 were considered significant. 3.13 Ethical Consideration Ethical clearance was obtained from the University of Liberia PIRE Ethics Board. {Protocol # 20-02-201}, An introductory letter was taken from the Department of Epidemiology of the School of Public Health and permission was sought from Liberia Education Ministry as well as principals of the selected schools. Permission was also obtained from the County Education Officer and a copy of the permission was sent to the principals of SHS selected for the study. University of Ghana http://ugspace.ug.edu.gh 28 CHAPTER FOUR 4.0 RESULTS 4.1 Socio-demographic characteristics of participants The 402 participants surveyed, 201 (50.0%) were males. Participants were between 13 to 24 years with mean age of 19.9 ± 1.7 years. Those between the ages of 19 to 21 years were 298 (74.1%). One-hundred and sixty-four (40.8%) were in SHS 1. Class 11 had 140 (34.8%) participants and they constituted the majority. On religious denomination, 302 (75.1%) of participants were Christians. Students who had both parents as their guardian were 192 (47.8%) and that constituted the majority. Students with 1 to 3 other siblings were 337 (83.8%) while only 17 (4.2%) had 6 or more other siblings (Table 4.1) Table 4.1: Socio-demographic characteristics of participants Variables Frequency Proportion (%) N=402 Age group <= 15years 15 3.7 16 - 18years 29 7.2 19 - 21years 298 74.2 22 -24years 60 14.9 Sex Female 201 50.0 Male 201 50.0 School SHS 1 164 40.8 University of Ghana http://ugspace.ug.edu.gh 29 SHS 2 95 23.6 SHS 3 143 35.6 Class 10 125 31.1 11 140 34.8 12 137 34.1 Religion Christianity 302 75.1 Islam 100 24.9 Guardian Both parents 192 47.8 Self 13 3.2 Only father 42 10.5 Only mother 130 32.3 Relative 25 6.2 Number of siblings 1 to 3 337 83.8 4 to 5 48 11.9 6 or more 17 4.3 4.2 Socio-economic characteristics of participants Of the 402 students surveyed, only 17 (4.2%) had guardian/parents who were unemployed. Majority of students indicated they had their sibling/siblings employed while 187 (46.5%) indicated their sibling/siblings were not employed. Aside schooling, 180 (44.8%) of the 402 University of Ghana http://ugspace.ug.edu.gh 30 students surveyed indicated they were working. When average pocket money of students were enquired, 243 (60.4%) indicated 100 to 300 Liberian Dollars. Most students, 283 (70.4%) traced their source of money to their parents (Table 4.2) Table 4.2: Socio-economic characteristics of participants Variables Frequency Proportion (%) N=402 Guardian/parent employment Unemployed 17 4.2 Salaried worker 203 50.5 Farmer 9 2.2 Petty trading 152 37.8 Other 21 5.2 Siblings employment Unemployed 187 46.5 Salaried worker 69 17.2 Farmer 13 3.2 Fisherman/woman 6 1.5 Trader 127 31.6 Student work aside schooling Yes 180 44.8 No 222 55.2 Average pocket money <= 99 Liberian Dollars 35 8.7 100 - 300 Liberian Dollars 243 60.4 > 300 Liberian Dollars 63 15.7 Nothing/don't know 61 15.2 University of Ghana http://ugspace.ug.edu.gh 31 Source of money Gifts or from working 100 24.9 Guardians 19 4.7 Parents 283 70.4 4.3 Prevalence of substance use among students As shown in figure 2 below, of the 402 students surveyed, 291 (72.4%) had ever used a substance before. Prevalence of substance use was therefore 72.4% (95%CI = 67.8% – 76.6%). Of these 291 students, use of only alcohol was indicated in 255 (87.6%) students (Figure Figure 2: Prevalence of substance use among students 72.4% 27.6% Ever used substance Never used substance University of Ghana http://ugspace.ug.edu.gh 32 Figure 3: Types of substances used by students and the proportion of usage 4.4 Students knowledge/awareness of substance use by somebody/some people Of the 402 students, 395 (98.3%) knew someone who uses or ever used a substance. Majority, 171 (43.3%) of these 395 students revealed that the person they knew who uses or ever used a substance was their friend. Only 1 (0.3%) indicated the person was a parent. Majority, 335 (84.8%) of the 395 students revealed that the person they know uses/used only alcohol (Table 4.4) 1.4% 1.4 3.8% 5.8% 87.6 Alcohol, tobacco and/or marijuana Marijuana and cocaine only Other Tobacco and/or marijuana only Only alcohol Proportion S u b st a n ce s University of Ghana http://ugspace.ug.edu.gh 33 Table 4.4: Students knowledge/awareness of substance use by somebody/some people Variables Frequency Proportion (%) Know of anybody who use or ever used substance Yes 395 98.3 No 7 1.7 Relationship with person Classmate 84 21.3 Friend 171 43.3 Neighbor 42 10.6 Parent 1 0.3 Relative 23 5.8 School mate 70 17.7 Teacher 4 1.0 Substances used by this known person Only alcohol 335 84.8 Tobacco and/or marijuana only 21 5.3 Alcohol, tobacco and/or marijuana only 21 5.3 Marijuana and cocaine only 5 1.3 Other 13 3.3 4.5 Substance usage by students and/or persons known to them Overall, 398 students indicated they had either ever used a substance or know someone who uses/used a substance. Of this number, 332 (83.4%) indicated usage of substance still persist. Of this 332 students, usage of only alcohol was highest with 285 (85.8%) students. Of the 398 University of Ghana http://ugspace.ug.edu.gh 34 students, 147 (36.9%) revealed age at first time use of substance by them or the person they claimed to know was 18 to 20years and this constituted the majority. Of the 398 students, 208 (52.3%) were introduced to substance use by friends. Substance was mostly taken at home as revealed by 338 (84.9%) of the 398 students. Substance was mostly bought ‘‘in the area’’ as revealed by 273 (68.6%) of the 398 students. Majority, 346 (86.9%) indicated there has not been any harm to oneself or others due to influence of substance in the past year (Table 4.5) Table 4.5: Substance usage by students and/or persons known to them Variables Frequency Proportion (%) Do you/the person still use substances Yes 332 83.4 No 66 16.6 If yes, which substances Only alcohol 285 85.8 Tobacco and/or marijuana only 17 5.1 Alcohol, tobacco and/or marijuana only 19 5.7 Only cocaine 3 0.9 Marijuana and cocaine only 3 0.9 Other 5 1.5 Age at first substance use by you/the person 15 - 17years 79 19.9 18 - 20years 147 36.9 21 - 23years 53 13.3 24years or more 119 29.9 Who introduced you/the person to use substance University of Ghana http://ugspace.ug.edu.gh 35 Drug pushers 6 1.5 Family member 20 5.0 Friends 208 52.3 Myself 141 35.4 Other 23 5.8 Venue where substance is mostly taken Home 338 84.9 School 27 6.8 Both home and school 33 8.3 Place substance is bought Beach 19 4.8 Dealers 11 2.8 Ghettos 18 4.5 In the area 273 68.6 Market 77 19.3 Harm to oneself or others in the past year due to the influence of substance Yes 52 13.1 No 346 86.9 4.6 Reasons for substance use Of the 398 students who had ever used substance or know someone who uses/used substance, 351 (88.2%) indicated they had reasons for using substance. Out of this 351 students, 191 (54.4%) indicated reason for substance use is just to have fun. Of the 398 students, 117 (29.4%) revealed that curiosity led them or some people they know to take substance for the first time (Table 4.6) University of Ghana http://ugspace.ug.edu.gh 36 Table 4.6: Reasons for substance use Variables Frequency Proportion (%) You/the person have reason for using substance Yes 351 88.2 No 14 3.5 Don't know 33 8.3 If yes, reason To cope with stress 21 6.0 When I am bored 10 2.8 I like the feeling 66 18.8 To be like my friend 9 2.6 To have fun 191 54.4 To relax 54 15.4 What influenced you/the person to take first substance Curiosity 117 26.9 Encouraged by friends 107 51.6 Offered by parents or relatives 56 14.1 To overcome problems 91 22.9 To get high 27 6.8 4.7 Effects of substance use on students or persons known to them in the last year Of the 398 students, 129 (32.4%) indicated that at no point in time in the last year were they or some persons known to them unable to do homework or study for test due to effects of substance use. Of the 398 students, 316 (79.4%) indicated that at no point in time in the last University of Ghana http://ugspace.ug.edu.gh 37 year were they or some persons known to them got into a fight with other people. The experience of missing out on other things because much time was spent on getting high was not experienced by 325 (81.7%) of the 398. Going to school intoxicated with a substance in the last year was absent in 333 (83.7%) of the 398. Of the 398 students, 351 (88.2%) never caused shame or embarrassment to someone at any point in time in the last year by themselves or some persons known to them. The history of neglecting duties and responsibilities due to effects of substances was absent in 250 (62.8%) of the 398 students. Being shunned by friends and relatives was not experienced/witnessed by 333 (83.7%) of the 398. Of the 398 students who had ever used a substance or know of someone who uses/used substance, 170 (42.7%) missed at least a day at school in the last year due to the harmful effects of substance use. Of the 398, only 49 (12.3%) were involved in an accident that resulted in injury to oneself or others due to substance use in the last year. Of the 398 students, 214 (53.8%) had not receive any advice from friend, neighbours or relatives to quit substance use in the last year (Table 4.7) Table 4.7a: Effects of substance use on students or persons known to them in the last year Variables Frequency Proportion (%) Unable to do homework or study for test None 129 32.4 1 - 2times in a year 178 44.7 3 - 5times in a year 54 13.6 More than 5times in a year 37 9.3 Got into a fight with other people (friends, relatives, strangers) None 316 79.4 1 - 2times in a year 57 14.3 University of Ghana http://ugspace.ug.edu.gh 38 3 - 5times in a year 18 4.5 More than 5times in a year 7 1.8 Missed out on other things because much time was spent on getting high None 325 81.7 1 - 2times in a year 41 10.3 3 - 5times in a year 22 5.5 More than 5times in a year 10 2.5 Went to school high None 333 83.7 1 - 2times in a year 26 6.5 3 - 5times in a year 20 5.0 More than 5times in a year 19 7.8 Caused shame or embarrassment to someone None 351 88.2 1 - 2times in a year 14 3.5 3 - 5times in a year 25 6.3 More than 5times in a year 8 2.0 Neglected duties and responsibility None 250 62.8 1 - 2times in a year 122 30.7 3 - 5times in a year 14 3.5 More than 5times in year 12 3.0 University of Ghana http://ugspace.ug.edu.gh 39 Table 4.7b: Effects of substance use on students or persons known to them in the last year Variables Frequency Proportion (%) Shun by friends and relatives None 333 83.7 1 - 2times in a year 31 7.8 3 - 5times in a year 15 3.8 More than 5times in a year 19 4.8 Missed a day at school None 57 14.3 1 - 2times in a year 170 42.7 3 - 5times in year 100 25.1 More than 5times in a year 71 17.8 Found oneself in a place that one could not remember getting there None 347 87.2 1 - 2times in a year 19 4.8 3 - 5times in a year 11 2.8 More than 5times in a year 21 5.3 Passed out or fainted suddenly None 368 92.5 1 - 2times in a year 14 3.5 3 - 5times in a year 16 4 Ever been involved in an accident due to substance use that resulted in injury either to oneself or others University of Ghana http://ugspace.ug.edu.gh 40 Yes 49 12.3 No 349 87.7 Was told by a friend, neighbor, or relative to stop using substances None 214 53.8 1 - 2times in a year 109 27.4 3 - 5times in a year 34 8.5 More than 5times in a year 41 10.3 4.8 Association of socio-demographic characteristics with personal usage of substances among students Of the 402 students surveyed, 291 had ever used a substance before while 111 indicated they had never used a substance before. Of the 291 who had ever used substance before, 221 (76.0%) were within the age group 19 to 21years. Of the 111 students who had never used substance before, 77 (69.4%) were also within the age group 19 to 21years. There was statistically significant association between age group and use of substance (𝑥2 = 16.4, p-value = 0.001). There was no association between sex and use of substance (𝑥2 = 2.1, p-value = 0.147). Of the 291 students who had ever used substance, 120 (41.2%) were in SHS 1. Of the 111 who had never used substance, 44 (39.6%) were in SHS 1. There was no statistically significant association between school and use of substance (𝑥2 = 4.7, p-value = 0.095). Of the 291 students who had ever used substance, majority 116 (39.9%) were in form 12 while majority 48 (43.2%) of the 111 who had never used substance were in form 10. Association between form and substance use was significant (𝑥2 = 18.02, p-value < 0.001). Of the 291 students who had ever used substance, 219 (75.3%) were Christians while 83 (74.8%) of the 111 who had never used substance were also Christians. Association between religion and use of substance University of Ghana http://ugspace.ug.edu.gh 41 was not significant (𝑥2 = 0.01, p-value = 0.92). Of the 291 students who had ever used substance, 113 (38.8%) indicated their guardian was only their mothers. Of the 111 students who had never used substance, 80 (72.1%) had both parents as their guardians. There was statistically significant association between religion and use of substance (p-value <0.001). of the 291 who had ever used substance and the 111 who had never used substance, 247 (84.9%) and 90 (81.1%) respectively had 1 to 3 siblings. There was statistically significant association between number of siblings and use of substance (𝑥2 = 12.94, p-value = 0.002) (Table 4.8) Table 4.8: Bivariate analysis of socio-demographic characteristics for usage of substances among students Variables Ever used Never used 𝑥2 P-value N= 291 (72.4%) N= 111 (27.6%) Age group 16.4 0.001* <= 15years 10 (3.4) 5 (4.5) 16 - 18years 12 (4.1) 17 (15.3) 19 - 21years 221 (76.0) 77 (69.4) 22 -24years 48 (16.5) 12 (10.8) Sex 2.1 0.147 Female 139 (47.8) 62 (55.9) Male 152 (52.2) 49 (44.1) School 4.7 0.095 SHS 1 120 (41.2) 44 (39.6) SHS 2 61 (21.0) 34 (30.6) SHS 3 110 (37.8) 33 (29.7) Form 18.02 <0.001* 10 77 (26.5) 48 (43.2) University of Ghana http://ugspace.ug.edu.gh 42 11 98 (33.7) 42 (37.8) 12 116 (39.9) 21 (18.9) Religion 0.01 0.92 Christianity 219 (75.3) 83 (74.8) Islam 72 (24.7) 28 (25.2) Guardian <0.001†* Both parents 112 (38.5) 80 (72.1) Self 13 (4.5) 0 (0.0) Only father 33 (11.3) 9 (8.1) Only mother 113 (38.8) 17 (15.3) Relative 20 (6.9) 5 (4.5) Number of siblings 12.94 0.002* 1 to 3 247 (84.9) 90 (81.1) 4 to 5 38 (13.1) 10 (9.0) 6 or more 6 (2.1) 11 (9.9) †Fisher’s exact test; †*Significant (p<0.05) using Fisher’s exact test; *Significant (p<0.05) using chi-square test 4.9 Association of socio-economic characteristics with usage of substances among students Of the 291 students who had ever used a substance, 133 (45.7%) had their guardian/parents being salaried workers. Of the 111 students who had never used a substance, 70 (63.1%) also had their guardian/parents being salaried workers. There was statistically significant association between guardian/parents’ employment and use of substance by students (p-value <0.001). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 124 (42.6%) and 63 (56.8%) respectively had unemployed siblings. There was statistically significant association between sibling’s employment and use of substance by students (p-value = 0.003). Of the 291 students who had ever used a substance, University of Ghana http://ugspace.ug.edu.gh 43 150 (51.6%) indicated they work aside schooling. Of the 111 students who had never used a substance, 30 (27.0%) were working aside schooling. Association between student working aside schooling and substance use was statistically significant (𝑥2 = 19.54, p-value <0.001). Majority of students in both those who had ever used a substance and those who had never used a substance indicated their average pocket money were in the range of 100 to 300 Liberian Dollars. There was no association between average pocket money and use of substance ((𝑥2 = 2.97, p-value = 0.397). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 186 (63.9%) and 97 (87.4%) respectively traced their source of money to their parents. There was statistically significant association between source of money and use of substance by students (p-value < 0.001) (Table 4.9) Table 4.9: Bivariate analysis of socio-economic characteristics for usage of substances among students Variables Ever used Never used 𝒙𝟐 P-value N= 291 (72.4%) N= 111 (27.6%) Guardian/parent employment <0.001†* Unemployed 9 (3.1) 8 (7.2) Salaried worker 133 (45.7) 70 (63.1) Farmer 9 (3.1) 0 (0.0) Petty trading 126 (43.3) 26 (23.4) Other 14 (4.8) 7 (6.3) Siblings employment 0.003†* Unemployed 124 (42.6) 63 (56.8) Salaried worker 47 (16.2) 22 (19.8) Farmer 13 (4.5) 0 (0.0) University of Ghana http://ugspace.ug.edu.gh 44 Fisherman/woman 4 (1.4) 2 (1.8) Trader 103 (35.4) 24 (21.6) Student work aside schooling 19.54 <0.001* Yes 150 (51.6) 30 (27.0) No 141 (48.4) 81 (73.0) Average pocket money 2.97 0.397 <= 99 Liberia Dollars 29 (10.0) 6 (5.4) 100 - 300 Liberia Dollars 174 (59.8) 69 (62.2) > 300 Liberia Dollars 47 (16.2) 16 (14.4) Nothing/don't know 41 (14.1) 20 (18.0) Source of money <0.001†* Gifts or from working 90 (30.9) 10 (9.0) Guardians 15 (5.2) 4 (3.6) Parents 186 (63.9) 97 (87.4) †Fisher’s exact test; †*Significant (p<0.05) using Fisher’s exact test; *Significant (p<0.05) using chi- square test 4.10 Association of knowledge on substances with use of substances among students All 402 students surveyed indicated they had heard of at least one substance. Of the 291 students who had ever used a substance, 151 (51.9%) indicated they had heard of alcohol, tobacco (cigarette), and/or marijuana only. Of the 111 students who had never used a substance, 74 (66.7%) indicated they had heard of alcohol, tobacco (cigarette), and/or marijuana only. There was statistically significant association between substance heard of and use of substance (p-value = 0.008). Only 2 (1.8%) of the 111 students who had never used a substance indicated they had never seen a substance before. No association was found between ever seen a substance before and use of substance (p-value = 0.076). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 119 (40.9%) and 49 University of Ghana http://ugspace.ug.edu.gh 45 (45.0%) respectively had seen only alcohol. There was statistically significant association between substance seen and use of substance (p-value = 0.001). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 288 (99.0%) and 107 (96.4%) respectively knew of someone who uses/had ever used a substance. Association between knowing someone who uses/used a substance and personal usage of substance was not significant (p-value = 0.095). On assessing the relationship of students with the persons known to them who uses/used a substance, 151 (52.4%) of the 291 students who had ever used a substance indicated the persons were their friends. Majority, 32 (29.9%) of the 111 students who had never used a substance revealed the persons known to them who uses/used a substance were their schoolmates. There was statistically significant association between relationship with person and use of substance (p-value < 0.001). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 252 (87.5%) and 83 (77.6%) respectively revealed substance used by the persons known to them was only alcohol. Association between substances used by persons known to students and the personal usage of substance by students was statistically significant (p-value < 0.001) (Table 4.10) Table 4.10: Bivariate analysis of knowledge on substances for usage of substances Variables Ever used Never used 𝒙𝟐 P-value N= 291 (72.4%) N= 111 (27.6%) Substances heard of 0.008†* Only alcohol 58 (19.9) 24 (21.6) Tobacco and/or marijuana only 8 (2.8) 2 (1.8) Alcohol, tobacco and/or marijuana 151 (51.9) 74 (66.7) University of Ghana http://ugspace.ug.edu.gh 46 Alcohol, cocaine, tobacco and/or marijuana 61 (21.0) 9 (8.1) Cocaine or heroin only 8 (2.8) 0 (0.0) Other 5 (1.7) 2 (1.8) Ever seen substance before 0.076† Yes 291 (100.0) 109 (98.2) No 0 (0.0) 2 (1.8) Substance seen 0.001†* Only alcohol 119 (40.9) 49 (45.0) Tobacco and/or marijuana only 87 (29.9) 49 (45.0) Alcohol, tobacco and/or marijuana 48 (16.5) 8 (7.3) Alcohol, cocaine, tobacco and/or marijuana 7 (2.4) 0 (0.0) Cocaine or heroin only 21 (7.2) 1 (0.9) Other 9 (3.1) 2 (1.8) Know of anybody who use or ever used substance 0.095† Yes 288 (99.0) 107 (96.4) No 3 (1.0) 4 (3.6) Relationship with person <0.001†* Classmate 53 (18.4) 31 (29.0) Friend 151 (52.4) 20 (18.7) Neighbour 22 (7.6) 20 (18.7) Parent 1 (0.35) 0 (0.0) Relative 22 (7.6) 1 (0.9) Schoolmate 38 (13.2) 32 (29.9) University of Ghana http://ugspace.ug.edu.gh 47 Teacher 1 (0.3) 3 (2.8) Substances used by this known person <0.001†* Only alcohol 252 (87.5) 83 (77.6) Tobacco and/or marijuana only 17 (5.9) 4 (3.7) Alcohol, tobacco and/or marijuana only 4 (1.4) 17 (15.9) Marijuana and cocaine only 4 (1.4) 1 (0.9) Other 11 (3.8) 2 (1.9) †Fisher’s exact test; †*Significant (p<0.05) using Fisher’s exact test 4.11 Association of knowledge on effects of substance use on persons, family and community with use of substance among students Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 171 (58.8%) and 51 (46.0%) respectively knew substances cause tiredness/sickness in individuals who use substances. There was no statistically significant association between knowledge on effects of substances on a person and use of substance (p-value = 0.098). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 146 (50.2%) and 69 (62.2%) respectively knew use of substances lead to disgrace on families. There was statistically significant association between knowledge on effects of substances on the family and use of substance (p-value = 0.001). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, 200 (68.7%) and 76 (68.5%) respectively knew substances use lead to crime/violence in the community. Association between knowledge on effects of substances on the community and use of substance was statistically significant (p-value = 0.014). Of the 291 students who had ever used a substance and the 111 students who had never used a substance, only 18 (6.2%) and 12 (10.8%) respectively never knew possession and use of substances is an offence in Liberia. There was no association between awareness that University of Ghana http://ugspace.ug.edu.gh 48 possession and use of substance is an offence in Liberia and the use of substance (p-value = 0.622) (Table 4.11) Table 4.11: Bivariate analysis of knowledge on effects of substance use on persons, family and community for the use of substance among students Variables Ever used Never used 𝒙𝟐 P-value N= 291 (72.4%) N= 111 (27.6%) Effects of substances on a person 0.098† Bad temper 38 (13.1) 17 (15.3 Failure to do well at school/work 79 (27.1) 42 (37.8) Fear/disturbed sleep 3 (1.0) 1 (0.9) Tiredness/sickness 171 (58.8) 51 (46.0) Effects of substances on the family 0.001†* Worry/fear 14 (4.8) 4 (3.6) Breakdown in family relationship 57 (19.6) 18 (16.2) Disgrace 146 (50.2) 69 (62.2) Loss of trust in child 46 (15.8) 20 (18.0) Sickness 28 (9.6) 0 (0.0) Effects of substances on the community 0.014†* Accidents 65 (22.3) 33 (29.7) Reduce productivity 26 (8.9) 2 (1.8) Crime/violence 200 (68.7) 76 (68.5) Aware that possession and use of substances is an offence 2.489 0.115 Yes 273 (93.8) 99 (89.2) No 18 (6.2) 12 (10.8) University of Ghana http://ugspace.ug.edu.gh 49 Do you have the urge to use any narcotic substance 0.622 Yes 2 (0.7) 1 (0.9) No 289 (99.3) 110 (99.1) †Fisher’s exact test; †*Significant (p<0.05) using Fisher’s exact test 4.12 Multiple logistic regression analysis for factors associated with substance use among senior high school students Multiple logistic regression analysis was conducted on all factors that were statistically significant at 95% CI and P value < 0.05 at the bivariate level of analysis. Overall, 14 variables were significant at the bivariate level of analysis. Of these 13 variables, 6 were statistically significant and had an association with substance use in the multiple logistic regression model (p-value< 0.05). These variables were, guardian, sibling employment, source of money, relationship with known person who uses/used substance, substances used by the known person, and knowledge on effects of substances use on the community. The magnitude of association are explored in table 4.11 using simple and multiple logistic regression analysis to determine the crude and adjusted odds ratios respectively, their corresponding 95%CI and p-values. With other variables controlled for, there is 4.59 folds increased odds of substance use among senior high school students with their guardian being only their mothers compared to senior high school students who have both parents (mother and father) as guardian (aOR = 4.59, 95% CI = 1.65 – 12.78). Controlling for other variables, there is 66% reduced odds of substance use in senior high school student with unemployed siblings compared to senior high school students who have siblings who are salaried workers (aOR = 0.34, 95%CI = 0.12 – 0.97). After adjusting University of Ghana http://ugspace.ug.edu.gh 50 for all other variables, there is an 82% reduced odds of substance use among senior high school students whose parents are their source of money compared to senior high school students whose source of money are from gifts or working (aOR = 0.18, 95%CI = 0.05 – 0.73). Adjusting for other variables, odds of substance use among senior high school students is 4.42 times higher among students have friends who use substance compared to students who have classmates who use substance (aOR = 4.42, 95%CI = 1.67 – 11.67). Controlling for other variables, there is 97% decreased odds of substance use if tobacco (cigarette) and/or marijuana is/are the substances used by a person known to a student compared to only alcohol use (aOR = 0.03, 95%CI = 0.004 – 0.19). With other variables controlled for, there is 12.65 folds increased odds of substance use among senior high school students with knowledge that substance use leads to crime/violence in the community compared to student who knew substance use leads to accidents in the community (aOR = 12.65, 95%CI = 3.84 – 41.65). University of Ghana http://ugspace.ug.edu.gh 51 Table 4.12a: Multiple logistic regression analysis for factors associated with substance use among students Variables Ever used Never used Unadjusted p-value Adjusted p-value N= 291 (72.4%) N= 111 (27.6%) OR (95% CI) OR (95%CI) Age group <= 15years 10 (3.4) 5 (4.5) Ref Ref 16 - 18years 12 (4.1) 17 (15.3) 0.35 (0.10 - 1.30) 0.117 1.95 (0.20 - 19.05) 0.567 19 - 21years 221 (76.0) 77 (69.4) 1.44 (0.48 - 4.33) 0.522 3.47 (0.37 - 32.78) 0.278 22 -24years 48 (16.5) 12 (10.8) 2.0 (0.58 - 6.95) 0.276 2.53 (0.23 - 27.51) 0.445 Form 10 77 (26.5) 48 (43.2) Ref Ref 11 98 (33.7) 42 (37.8) 1.45 (0.87 - 2.42) 0.15 1.49 (0.66 - 3.38) 0.342 12 116 (39.9) 21 (18.9) 3.44 (1.91 - 6.20) <0.001 2.40 (0.96 - 6.01) 0.062 Guardian Both parents 112 (38.5) 80 (72.1) Ref Ref Self 13 (4.5) 0 (0.0) Omitted Omitted University of Ghana http://ugspace.ug.edu.gh 52 Only father 33 (11.3) 9 (8.1) 2.62 (1.19 - 5.78) 0.017 1.69 (0.51 - 5.56) 0.389 Only mother 113 (38.8) 17 (15.3) 4.75 (2.64 - 8.52) <0.001 4.59 (1.65 - 12.78) 0.004 Relative 20 (6.9) 5 (4.5) 2.86 (1.03 - 7.93) 0.044 0.63 (0.09 - 4.55) 0.645 Number of siblings 1 to 3 247 (84.9) 90 (81.1) Ref Ref 4 to 5 38 (13.1) 10 (9.0) 1.38 (0.66 - 2.89) 0.387 1.76 (0.51 - 6.05) 0.371 6 or more 6 (2.1) 11 (9.9) 0.20 (0.07 - 0.55) 0.002 0.64 (0.07 - 5.73) 0.693 *Significant (p<0.05) Table 4.12b: Multiple logistic regression analysis for factors associated with substance use among students Variables Ever used Never used Unadjusted p-value Adjusted p-value N= 291 (72.4%) N= 111 (27.6%) OR (95% CI) OR (95%CI) Guardian/parent employment Unemployed 9 (3.1) 8 (7.2) Ref Ref Salaried worker 133 (45.7) 70 (63.1) 1.69 (0.62 - 4.57) 0.302 3.40 (0.36 - 31.87) 0.284 University of Ghana http://ugspace.ug.edu.gh 53 Farmer 9 (3.1) 0 (0.0) Omitted Omitted Petty trading 126 (43.3) 26 (23.4) 4.31 (1.52 - 12.21) 0.006 4.14 (0.35 - 48.52) 0.257 Other 14 (4.8) 7 (6.3) 1.78 (0.48 - 6.62) 0.391 3.80 (0.25 - 58.61) 0.339 Siblings employment Salaried worker 47 (16.2) 22 (19.8) Ref Ref Unemployed 124 (42.6) 63 (56.8) 0.92 (0.51 - 1.66) 0.785 0.34 (0.12 - 0.97) 0.04 Farmer 13 (4.5) 0 (0.0) Omitted Omitted Fisherman/woman 4 (1.4) 2 (1.8) 0.94 (0.16 - 5.50) 0.942 1.21 (0.05 - 27.24) 0.904 Trader 103 (35.4) 24 (21.6) 2.01 (1.02 - 3.94) 0.042 1.18 (0.30 - 4.61) 0.812 Student work aside schooling Yes 150 (51.6) 30 (27.0) 2.87 (1.78 - 4.63) <0.001 1.11 (0.37 - 3.37) 0.852 No 141 (48.4) 81 (73.0) Ref Ref Source of money Gifts or from working 90 (30.9) 10 (9.0) Ref Ref Guardians 15 (5.2) 4 (3.6) 0.42 (0.12 - 1.50) 0.181 1.45 (0.13 - 16.45) 0.764 Parents 186 (63.9) 97 (87.4) 0.21 (0.11 - 0.43) <0.001 0.18 (0.05 - 0.73) 0.016 *Significant (p<0.05) University of Ghana http://ugspace.ug.edu.gh 54 Table 4.12c: Multiple logistic regression analysis for factors associated with substance use among students Variables Ever used Never used Unadjusted p-value Adjusted p-value N= 291 (72.4%) N= 111 (27.6%) OR (95% CI) OR (95%CI) Substances heard of Only alcohol 58 (19.9) 24 (21.6) Ref Ref Tobacco and/or marijuana only 8 (2.8) 2 (1.8) 1.66 (0.33 - 8.37) 0.542 0.62 (0.01 - 66.47) 0.843 Alcohol, tobacco and/or marijuana 151 (51.9) 74 (66.7) 0.84 (0.49 - 1.47) 0.547 1.00 (0.34 - 2.95) 0.995 Alcohol, cocaine, tobacco and/or marijuana 61 (21.0) 9 (8.1) 2.80 (1.20 - 6.54) 0.017 3.73 (0.82 - 16.91) 0.088 Cocaine or heroin only 8 (2.8) 0 (0.0) Omitted Omitted Other 5 (1.7) 2 (1.8) 1.03 (0.19 - 5.70) 0.969 0.27 (0.02 - 4.96) 0.381 Substance seen Only alcohol 119 (40.9) 49 (45.0) Ref Ref Tobacco and/or marijuana only 87 (29.9) 49 (45.0) 0.73 (0.45 - 1.18) 0.204 1.47 (0.59 - 3.65) 0.409 Alcohol, tobacco and/or marijuana 48 (16.5) 8 (7.3) 2.47 (1.09 - 5.60) 0.03 1.51 (0.39 - 5.87) 0.551 Alcohol, cocaine, tobacco and/or marijuana 7 (2.4) 0 (0.0) Omitted Omitted University of Ghana http://ugspace.ug.edu.gh 55 Cocaine or heroin only 21 (7.2) 1 (0.9) 8.65 (1.13 - 66.07) 0.038 2.22 (0.04 - 112.27) 0.691 Other 9 (3.1) 2 (1.8) 1.85 (0.39 - 8.89) 0.441 35.46 (0.36 - 3507.16) 0.128 *Significant (p<0.05) University of Ghana http://ugspace.ug.edu.gh 56 Table 4.12d: Multiple logistic regression analysis for factors associated with substance use among students Variables Ever used Never