The Prevalence of Chat Chewing in Butajira

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The prevalence and socio-demographiccorrelates of khat chewing in Butajira,Ethiopia

Alem A, Kebede D, Kullgren G. The prevalence and socio-demographic

correlates of khat chewing in Butajira, Ethiopia.

Acta Psychiatrica Scand 1999: 100: 84-91. Munksgaard 1999

A house-to-house survey was carried out in a rural Ethiopian communityto determine the prevalence and socio-demographic correlates of khatuse. A total of 10 468 adults were interviewed. Of these, 58% were female,

and 740/0were Muslim. More than half of the study population (55.7%)reported lifetime khat chewing experience and the prevalence of currentuse was 50 . Among current chewers, 17.40/0 eported taking khat on adaily basis; 16.1% of these were male and 3.4% were female. Various

reasons were given for chewing khat; 80% of the chewers used it to gain agood level of concentration for prayer. Muslim religion, smoking andhigh educational level showed strong association with daily khatchewing.

Introduction

Khat (Catha edulis) is an evergreen plant that

grows mainly in Ethiopia, Kenya, Yemen, and at

high altitudes in South Africa and Madagascar. T he

plant is known by different names in different

countries: chat in Ethiopia, qat in Yemen, mirra in

Kenya and qaad or ja ad in Somalia, but in most of

the literature it is known as khat. In khat-growing

countries, the chewing of khat leaves for social and

psychological reasons has been practised for many

centuries. I ts use has gradually expanded to

neighbouring countries and beyond through com-

mercial routes. Recently, increasing numbers of

immigrants have spread the practice to Europe and

the United States (1). There is an indication that

immigrants might be using more khat in Europethan in their country of origin (2).

The origin of khat is not clear, but it is generally

agreed that khat is native to Ethiopia and was first

used there (3). Between the first and sixth centuries

(AD), khat was introduced to Yemen where later

the Danish botanist and physician Forsskal

(1736-1763) gave the name Catha edulis to the

plant growing on the mountain of A1.-Yaman (3).

Terms such as ‘Tea of the Arabs’ or ‘Abyssinian

Tea’ formerly used for khat indicate that dried

A. Alem’, D. Kebede , G Kullgren3’Amanu el Psychiatr ic Hospi tal . Addis Ababa,

’Department of Communi ty Heal th, Facul ty of

M ed ic ine , U n i vers i ty o f Addis Ababa, E thiopia, and

3Depa rtment of Psych iatry. Ume3 Universi ty, UmeB,

S w eden

Key word s khat chewing, prevalence, ethnict ty.

E thiopia

Atalay A lem, Arnanuel Psychiatr ic Hospi tal. P 0 Box

1971, Addis Ababa. E thiopia

leaves of khat were boiled and used as modern tea is

now (4). The Harar region of Ethiopia is universally

believed to be the origin of khat use and, not

surprisingly, people of Harar consider khat a

treatment for all kinds of different ailments (5 ) .

The medical use of khat goes back to the time of

Alexander the Great, who used khat to treat his

soldiers for an unknown ‘epidemic disease’ ( 5 ) .

Historically, khat has also been used as medicine to

alleviate symptoms of melancholia and depression.

Modern users report that chewing khat gives

increased energy levels and alertness, improves

self-esteem, creates a sensation of elation, enhances

imaginative ability and the capacity to associate

ideas, and improves the ability to communicate (6).

For some, chewing khat is a method of increasingenergy and elevating mood in order to improve their

work performance. Khat is also considered a

dietary requirement by some. It may also be used

to suppress hunger when there is shortage of food.

For many centuries the active ingredient in khat

was not known. Now it has been discovered that the

psycho-stimulant effect of khat is due to the

alkaloid chemical ingredient cathinone present in

the fresh leaves of the plant. Cathinone’s chemical

structure is similar to amphetamine. The results of

8



Khat chewing in Butajira

various rz vivo and in vitro experiments indicate thatthe substance could be considered a ‘naturalamphetamine’ (7, 8). The effects of cathinone inanimals correspond to those observed in khat-usinghumans. The pattern of dependence cathinoneproduces is also similar to that of amphetamine.Consequently, WHO has recommended that cath-inone be put under international control and it isnow included in the list of controlled drugs. Becauseof cathinone’s similarity to amphetamine, there isreason to believe that the effect of khat on healthmay be similar to that of amphetamine. Thediffering effects on health are mainly due todifferences in dosage and mode of application (9).

Compared to amphetamine, khat is less likely to

cause tolerance perhaps because there are physicallimits to the amount that can be chewed. Khat issaid to cause persistent psychic dependence rather

than physical dependence (10, 11). However, truewithdrawal symptoms, such as profound lassitude,anergia, difficulty in initiating normal activity, andslight trembling, several days after ceasing to chewhave been reported. Nightmares, often paranoid innature of being attacked, strangled or followed, arealso other symptoms of withdrawal.

Most people chew khat in groups during specialceremonies intended to enhance social interactionor facilitate contact with Allah by Muslims. In fact,in some localities buildings and homes are archi-tecturally designed to include rooms that comfor-tably accommodate khat ceremonies. Morghem andRufat 12) describe khat chewing ceremonies as

follows: the khat ceremonies conform to a specificpattern. Friends gather in the allocated room. Theyspread mattresses on the floor upon which theyrecline leaning against the wall with their elbowsresting on pillows. Some prefer to keep a blaze ofcharcoal in the centre of the room to burn incense.Only tender khat leaves and stems are chewed, andthe juice is swallowed. The residue accumulates inthe mouth until the end of the session and the bolusmakes a characteristic bulge in the cheek of thechewer. During the session, fluids like tea and softdrinks are consumed; often music is played. In suchsessions a high level of social interaction is achievedand most important topics for discussion are

reserved for such sessions, Individuals who reg-ularly hold the ceremony strive to get the best out ofevery session. An average of two to three hours isspent on the khat ceremony every day by someregular users. Such parties are mostly attended bymen and mixed parties with women are rare.

Many observers have reported a negative impacton health and socio-economic conditions in com-munities where khat is used regularly (13). Almostall classes of people use khat in places where its useis endemic. However, the urban poor are believed to

be most negatively affected. Some estimate that asmuch as 85 of men’s monthly income may bespent on khat in some communities (13). Somereports indicate that khat consumption has adverse

consequences for married life. Spending money tomaintain the habit and wasting time at the khatceremonies lead to family neglect and, conse-quently, to divorce. In some cases deterioration ofsexual activities and estrangement between spousesis also reported. In a Somali study, 18.8 of themale respondents reported improvement of sexualperformance after khat chewing, but 61Yn reportedthat it caused impairment (13). Regular use of khatcan reduce working hours and capacity for workwhen the substance is not used. This is believed toreduce the economic growth of a country (4). On theother hand, the economic benefit from the sale of

khat is said to be high. A considerable amount of

revenue is generated from khat export by countriesthat grow khat.

There are several reports on unwanted physicaland psychological effects among regular chewers ofthe substance. More cases of low birth weight andstill birth among khat chewing mothers than amongnon-users has been reported (14) . It has also beenreported that khat addiction has a deleterious effecton semen parameters and deforms sperm cells 15).Gastritis, malnutrition, constipation, anorexia,spermatorrhea, arrhythmias, impotence, elevationof blood pressure, are among other physical effectsreported in khat users (16, 17). Insomnia, anxiety,depression on cessation, tension, and variouspsychotic symptoms are also reported by differentinvestigators (11). Until 1995, 16 cases of khat-induced psychoses have been reported in Europeand America among African and Arab immigrants18). Paranoid state, schizophreniform psychosis,

Capgras Fregoli syndrome, acute schizophrenia-likepsychotic syndrome, and mania were the primarydiagnoses given to the cases until relationshipsbetween the onsets or recurrences of symptoms andkhat consumption were discovered 1 8-22). In twoof the cases, homicide and combined homicide andsuicide following consumption of khat werereported (19). In most of those cases, heavy khat

consumption preceded the psychotic episodes. Werecently reported a khat-related case that wasadmitted to Amanuel Mental Hospital from thecentral prison in Addis Ababa by court order for asanity evaluation. He had repeatedly displayedviolent behaviour following heavy khat consump-tion with spontaneous remission in a couple of daysor weeks. During one such episode, he had violentlykilled his wife and his daughter and injured hiscattle (23). It is also a familiar experience of theprimary author of this paper to observe a high

85



Alem t al.

proportion of khat chewers among inpatients at

Amanuel Mental Hospital.

Khat use is legal in Ethiopia. Khat chewing has

been a daily practice in many Ethiopian commu-

nities for many generations. The practice, with itsalleged ill effects, is currently spreading throughout

the country (24).

In general, there is only a limited amount of data

on khat chewing in Ethiopia. The two epidemiolo-

gical studies available thus far are based on small

samples of students (25, 26), which may not reflect

the situation in communities. So far, no commu-

nity-based study has been conducted in the country.

We feel that such data are essential for policy issues,

further studies and planning in health. We report

here on the results of a survey conducted in a rural

community as one of the important components of

the general mental health survey.

Materi al and methods

Study area

The study was conducted in Butajira, one of the

rural districts of Ethiopia. It is located 130 km

south of Addis Ababa and is one of the most

densely populated districts in the country. Although

the area’s major ethnic group is Gurage and the

population is predominantly Muslim, there is also a

minority of persons from diverse ethnic groups, and

there is a substantial Orthodox Christian commu-

nity. Butajira is the only major town in the area. The

district’s health needs are served by one health

centre inside the town and two health stations and

four health posts outside the town. The mainstay of

the district’s economy is farming; peppers and khat

are the main cash crops. Kocho, a fibrous bread

prepared from the stem of the false banana plant, is

the staple diet.

A rural health project was started in this district

in 1986 as a collaborative research undertaking

between the Department of Community Health,

Faculty of Medicine, Addis Ababa University,

Ethiopia, and the Department of Epidemiology

and Public Health, Ume& University, Sweden. The

objectives of the project were to establish a

demographic study base for research on essentialhealth problems in a rural area and to develop and

strengthen the research capacity and infrastructure

for this purpose. Detailed descriptions of the base

are reported elsewhere (27).

Ins t rument

This study was combined with a general mental

health survey in the study base that used the Self

Reporting Questionnaire (SRQ) to assess mental

distress (28). Nine questions for this study and other

86

questions on problem drinking and suicide attempt

were added to the SRQ. A few questions to enquire

about income and cigarette smoking were included

as well.

The questions used for this study were the

following:

(i) Have you ever chewed khat? (no/yes)

(ii) If yes, how long have you chewed? (in years)

(iii) Do you chew now? (no/yes)(iv) If yes, how often?

(v) If you are chewing daily, what time of day?(morning/day time/evening/if more than once,

specify)

(vi) What is the reason for you to chew khat? (forpleasure/to socialize/to prevent the withdrawal

effect/to pass time/for prayer/other, specify)

(vii) Do your small children also chew khat? (no/

(viii) If yes, at what age (in years) do they start? (lessthan 5/5-9/10-15)

ix) How do you get khat? (own fardbuy it/ownfarm and buying/other, specify)

Yes)

Des ign

The design of the study is described elsewhere in

detail (28). Briefly, 21 high school graduates were

recruited from the town of Butajira to collect data.

They were given three days’ training in interview

techniques and how to complete the questionnaire.

Initially, the questionnaire was pretested on 40people from villages not included in the study. None

of these individuals had any negative reactions to

any of these questions. The survey was performed

between November 1994 and January 1995.

St a t i s t i ca l a na lys i s

The EPI-INFO version 5 computer program was

used for data entry and preliminary analysis. Chi-

square analysis was employed to compare inter-

group distribution using SPSS version 7.

ResultsThe survey included 5259 houses where 12531

persons above the age of 15 resided. Fifteen per cent

of these persons (n=1873) did not respond to the

questionnaire. Individuals who were not found at

home on three consecutive visits accounted for 91%

of the non-respondent group. Nine per cent (n= 173)

of the non-respondents failed to participate because

of various personal reasons. Some of these indivi-

duals were prevented from responding because of

physical or mental illnesses. From those who did




Table 1 Distribution of daily khat chewing according to socio demographic factors, stratified for sex

Male FemaleKhat

chewers chewers StatisticsPopulation chewers ~~

Variable n n n n Chi square df P-value

Age

15-24

25-44

45-59

60+

Religion

Christian

Muslim

Marital status

Single

Married

Divorced

Widowed

Illiterate

Elementary

Secondary+

Ethnicity

Gurage

Others

Income 1

Income 2

Income 3

Problem drinking

No

Yes

Smoking

No

Mi ld

Moderate

Heavy

Mental distress

No

Yes

Total

Education

Income

2997

4669

1732

1089

2668

7800

2527

681 1

254

876

8295

1514

651

8668

1800

7948

1047

196

10 083

385

10088

186

132

141

8642

1826

10 468

195

496

159

64

86

825

212

636

21

42

603

122

136

838

73

697

112

21

853

58

773

46

47

59

756

155

911

158

381

120

47

76

630

189

494

14

9

430

153

123

648

58

539

97

17

650

56

573

46

45

56

596

110

706

12 0

21 5

15 3

9 0

6 9

1 9 2

13 5

17 2

21 2

13 2

14 8

14 7

28 6

17 6

8 4

15 6

1 9 4

18 3

16 0

17 0

1 4 3

25 4

35 2

42 7

16 0

17 0

16 1

37

115

36

17

10

195

23

142

7

33

173

19

13

190

15

158

15

4

203

2

200

0

2

3

160

45

205

2 2

4 0

3 9

3 0

0 6

4 3

2 0

3 6

3 4

4 1

3 2

4 0

5 7

3 8

1 4

3 5

2 5

3 9

3 4

3 6

3 3

0 0

50 0

30 0

3 3

3 8

3 4

M+F=51 24

M=73 48

F = l l 40

M+F=13530

M=92 19

F=48 34

M+F=20 67

M = 1 6 0 2

F=8 08

M+F=148 34

M=55 10

F=4 70

M+F=59 09

M=36 12

F=1644

M+F=4 88

M=4 93

F=O 93

M+F=20 36

M=O 22

F = O 01

M+F=386 27

M=125 65

F=48 77

M+F=3 10

M=O 42

F=O 91

o 001

o 001

o 01

o 001

o 001

o 001

o 001

o 001

O 05

o 001

o 001

n s

o 001

(0 001

o 001

n s

n s

o 001

n s

n s

n s

o 001

<o 001

o 001

n s

n s

n s

not respond because of personal reasons, 13%

(n-22) were severely mentally ill. One hundred and

ninety questionnaires were found to be incomplete

and were excluded from the analyses.

The study population thus consisted of 10468

individuals. Over 50 were female, and there were

more respondents between the ages of 25 and 44

than in the other age categories. The majority of the

respondents belonged to the Gurage ethnic group,were Muslim, and had no formal education. Most

were married.

Income was divided into three levels based on

the annual income of families in birr as follows:

Income 1<1200, Income 2= 1200-6000, Income

3=6000+ (1 US =6.5 birr). There were 1277

(1 2.2'%1) ndividuals who were not able to specify

their income. Seventy-six per cent had an

estimated annual income equivalent to or less

than US 190.

More than half of the study population reported

lifetime khat chewing experiences. Among these, the

majority was male. The prevalence for current

chewing in both sexes was 50 with a higher

frequency among men (70%) compared to women

(35%). The duration of khat use ranged from less

than a year to 70 years. The median duration was 12years. Among the current chewers, 17.4% (n=911)

reported using the substance on a daily basis. Agreat majority (97%) of daily users reported

chewing only once a day, and the rest reported

chewing twice daily. Around noon is the preferred

time of day for chewing. Most consumers (57.3%)

buy their khat, and only 27% obtained the plant

from their own farms.

Various reasons for chewing khat were given. The

majority (80.0%) reported that they used khat to

obtain maximum concentration levels during

prayer. Of these, 96% were Muslim.



Alem t al.

Socializing or conformity with the norm was

given as the main reason for khat use by 25% of

the respondents, 12.1% used it to stabilize their

emotions, 0.6% took it because of dependence and

I .3%1 for concentration when studying, and for

efficiency at work.

Ten per cent (n=541) of the khat users reported

that their small children also chewed khat. Of these,

the majority (88.2%) reported that 10-15 years is the

age at which children start chewing. Twelve people

reported that even children under five chew khat.

Detailed analysis of socio-demographic correlates

was carried out only on those individuals who

chewed khat on a daily basis (Table 1). Chi-square

statistics are presented for both sexes combined and

after stratification. Daily khat chewing yielded

a significantly higher association with male than

with female sex (chi-square 520.37; P<O.OOl). All

variables were stratified for sex. Young adults andthe middle-aged showed higher associations for

daily chewing compared to adolescents. The highest

percentage of daily chewers were between the ages

of 25 and 44 years. Being Muslim was a significant

predictor of daily khat chewing in both sexes. There

is a significant association between high level of

education and khat chewing among men only. The

Gurage people were more likely to chew khat daily.

This difference was statistically significant. There

was an association between marital status and daily

khat chewing; among men it was the divorced and

among women, it was the widowed who were most

likely to be khat chewers.

People who smoked cigarettes were operationallyclassified into three groups based on the number of

cigarettes they smoked daily, as follows: 1-3=mild,

4-9=moderate, and >9=heavy. Cigarette smoking

showed a significantly higher association with khat

chewing than non-smoking. Heavy smokers showed

over a three-fold greater association than non-

smokers. Problem drinking was also associated with

khat chewing, but not so when stratified for sex.

There was no significant association between khat

chewing and general mental distress.

DiscussionEpidemiological studies on khat use are rare.

Baasher and Sadoun (4) reviewed the epidemiology

of khat chewing in their paper presented at the

International Conference on khat in Madagascar in

1983. According to their review, in 1972, a WHO-

sponsored mission to Yemen estimated that

approximately 80% of the adult men in major

cities and 90% of the men in khat-producing villages

were regular khat chewers. The prevalence was

estimated to be lower among women. Another

report on a study of 468 high school students in

Yemen showed that 12% of the students were khat

users. Ninety per cent of the students’ fathers and

60 ) of their mothers were khat users. In the

Democratic Republic of Yemen, in 1976, a group ofhealth workers estimated that 50 of the adult male

population indulged in khat chewing. In Somalia, in

1981 , it was estimated that about 75% of the men

and 7710% of the women chewed khat regularly,

and that khat use was increasing. In 1982, it was

estimated by WHO visitors that 90% of the men and

10% of the women regularly chewed khat in

Djibouti. In a randomly selected sample of general

outpatient clinic attenders in Kenya, it was found

that 29% were khat chewers and that only one of

them was female (29).

Our study indicates a lower prevalence of khat

use than previous general estimates from Yemen,

Djibouti and Somalia. However, there were fewerwomen who chewed khat reported in those

countries than in our population. The 1981 estimate

of 75% for men who chewed khat in Somalia is

comparable to the results of our study. The

differences between these estimates and our findings

may be that figures from those countries were mere

educated guesses rather than based on scientific

studies. If our study had been done in the 1970s and

the early 1980s, we may have obtained results

similar to the estimates in those countries, particu-

larly that of khat use by women. The emancipation

of women, which has been one of the movements in

Ethiopia for the last 20 years, may have increased

the number of khat chewing women in Butajira.

However, the prevalence of khat chewing among

men is still twice as high as that of women in this

study. This may be explained by the persisting

cultural restriction on women against the use of

such substances.

The prevalence of khat chewing in Butajira isclose to the prevalence (54.9%) reported among

the Hargeisa community in Somalia (7), but lower

than the prevalence of 64.9% among the Agaro

Secondary School students (26) in south-western

Ethiopia. The higher prevalence among the Agaro

students may be due to a population composition

that does not represent the general population. Thestudent population in our study was very low (3%)

and would not have a great impact on the results

when seen together with the rest of the population.

Similar studies among Mogadishu inhabitants in

Somalia (7) and among students at Gondar College

of Medical Sciences, Ethiopia (25) found a pre-

valence of 18.26% and 22.3%, respectively. The

lower prevalence in these studies might be explained

by relatively greater distances between those places

and khat-growing areas.

88




The significantly positive association between the

Muslim religion and daily khat chewing is similar to

the finding among Agaro students and to reports

from elsewhere (30). Khat growing and the practice

of chewing has traditionally been confined to the

lowlands of Ethiopia where the Muslim population

predominates and the habit could easily be passed

from generation to generation, as evidently shown

by the positive association of daily chewing and the

Gurage ethnic group in this study. The custom ofkhat chewing in group prayer sessions by Muslims

can also be one of the possible explanations for the

difference.

In this study, khat chewing was more frequent

between the ages of 25 and 44 and less common

after the age of 59. This finding is closer to the

results of a study in Mogadishu (7) that reported a

peak age of 2 04 0 and to a survey in Kenya 31 that

reported a peak age of 2 1 4 0 . In our study, 10% ofthe respondents reported that small children chew

khat with their parents. Most of these people

(88.2 ) reported that the age of onset of khat

chewing is 10-15 years. The median age of onset

reported by Agaro students was 14.6 years, and 16.4

years by Gondar students. This indicates that khat

consumption starts during the teenage years, peaks

during early adulthood, and declines after middle

age. The young adult and middle-aged and the more

educated groups who represent the most productive

sections of the society are most affected by the khat

chewing habit.

Kalix authoritatively reviewed the negative

health, socio-economic, and political effects ofkhat chewing in countries where the habit is

widespread (6). His argument for the negative

socio-economic effect was based on observations

regarding time and money spent to maintain the

habit. On the other hand, one might argue that

moderate use of khat might improve performance

and increase output of work because of its stimulant

and fatigue-postponing effects. The increased asso-

ciation of its use with those who have higher

educational attainment in this study and previous

studies (7,25,26 )might lead one to hypothesize that

prior khat use might have enabled these individuals

to progress in their education better than non-users.

Therefore, simple observation may not allow us todiscuss the negative or positive socio-economic

impact of khat chewing on those societies where

khat chewing is a common practice. However,

taking all the evidence together one is inclined to say

the negative effects of khat chewing outweigh

possible positive effects.

All users of khat in the Somali and Ethiopian

studies mentioned above obtain it by purchasing.

This includes students of the Agaro Secondary

School. which is located in an area where khat is

commonly grown. Most chewers among our study

population obtain the substance by buying it,

whereas 27% of the chewers grew it themselves.

This suggests that khat is a cash crop grown mainly

for economic reasons. In fact, because khat is a

drought-resistant plant, it does not require much

effort to cultivate, and generates more income than

other cash crops; farmers in khat-growing areas

destroy other cash crops, such as coffee, and replace

them with khat. In a study that compared the

income levels of two khat-growing and non-khat-

growing communities in a district of Hararghe

region in Ethiopia, it was shown that the mean

income per family in the khat-growing community

was 2704 birr compared to 875 birr in the non-khat-

growing community (32). The study also reported a

greater ownership of modern commodities and

facilities by the khat-growing community than

by the non-khat-growing community. Khat wasassessed as the source of 76.8% of income in the

khat-growing community, while crops, milk, and

fire-wood were the sources for 100% of the income

in the non-khat-growing community. That study

has also indicated the relative reluctance to grow

essential crops and breed cattle in the khat-growing

community. Such findings tempt one to compare

khat growers with those who invest relatively little

to grow and sell illicit drugs in order to make more

money than those who work harder to produce

essential products that contribute to their country’s

development and the well-being of its citizens.

The reasons given by our population for chewing

khat were to enhance concentration during prayerand study, to improve social interaction, to elevate

mood, and to avoid withdrawal symptoms. This

finding is similar to previous reports (6). This

indicates that khat has similar effects on users to

that of amphetamine and other psycho-stimulants.

Amongst our population, khat seems to be used

more when people engage in higher level mental

exercises, where alertness, concentration, high

imaginative capacity and social interaction are

required. Prayer and study are among the activities

that require high concentration and imagination.

The increase in khat use with increasing educational

level could be explained in the same way. People

with a high level of education are likely to beengaged with tasks that require imaginative think-

ing to a greater extent than those who are less

educated. It might also be that the immense pressure

of academic success at all levels (owing to fierce

competition) tempts young people to use khat in the

hope that it might increase their chances of being

successful. However, there are no studies to show

that khat increases intellectual performance. Many

drivers in Ethiopia, long distance truck drivers in

particular, are regular khat consumers. This group

9



Alem t al

of people chew khat to gain the maximum alertnessand concentration for their demanding job . Themost frequently stated reason for chewing khat wasto increase concentration during prayer. This maybe explained by the predominance of Muslimsamong the study population, reflected in the factthat 96% of those who gave this reason areMuslims.

In this study, 0.6% (n=29) reported that theycontinue to chew khat because of withdrawalsymptoms. This suggests that khat hardly causesphysical dependence.

The strong association of daily khat chewing withcigarette smoking in this study is in line withfindings from other studies 3 3 ) . Khat chewers arebelieved to take alcohol to break the stimulanteffect of khat after long hours of stimulation. Theexpression used for such a practice in one of the

Ethiopian languages, ‘mirkana chahsi’, connotesbreaking the effect. Contrary to findings in thatstudy, however, there was no association betweendaily khat chewing and problem drinking in ourstudy. There seemed to be an overall difference inproblem drinking between daily chewers and non-chewers, but when stratified for sex this was nolonger the case. The fact that the study by Omoloand Dhadphale was not a community sample andthat almost all of their subjects were male mightexplain the difference in the results.

There was no significant difference in the habi t ofkhat chewing between high and low scorers on a

mental distress scale measured by the SRQ.

Dhadphale and Omolo (34), in Kenya, reportedthat the prevalence of psychiatric morbidity was thesame among moderate chewers and non-chewers.However, they found a higher prevalence ofpsychiatric morbidity among excessive chewersthan among non-chewers. Since the attempt toquantify the amount of consumption was notsuccessful in our study, it was not possible toshow the dose-related effect of khat consumptionon mental health.

In conclusion, this study has shown that the khatchewing habit affects a majority of the adultpopulation in the Butajira district. The section

most affected by khat chewing seems to comprisethe most educated and the most productive agegroup of the community. Although the methodsemployed in measuring mental disorders in thissurvey were not very specific, general mentaldistress, as measured by the SRQ, has not beenshown to be associated with khat chewing. We

recommend an appropriately designed study to lookinto the effect of khat chewing on the socio-economy and health of a community where its use isvery common.

Acknowledgements

The study was financed by the Swedish Medical ResearchCouncil and the Swedish Agency for Research Co-operationwith Developing Countries through the Department ofPsychiatry, Umei University. Material assistance obtained

from the Department of Community Health, Addis AbabaUniversity and Amanuel Hospital is also acknowledged.

We would like to thank Drs. Ayana Yen eabat, Abeba Bekeleand Ato Teferi Gedif for assisting us in supervising the datacollection process.

We thank Professor R. Giel, Drs. Barbara Singleton, RobertKohn and Matthew Hotopf for their comments on an earlierdraft of this manuscript.

We also thank all the data collectors and the studyparticipants who kindly gave us the necessary information.

References

1.

2.

3.

4.

5 .

6.

7.

8.

9.

10

11.

12.

13.

14.

15.

N E N C I N I, GRASSSIC, BOTAN A, AS S EYR F , P A OLI.Khat chewing spread to the Somali community inRom e. Drug Alcohol Depend 1988: 23: 255-258.

GRIFFITHS, GOSSIP, W I C I K E N D E N, D U N W O K H, H A R R I SK, LLOYD . A transcultural pattern of drug use: qat(khat) in the U K. B r J Psychiatry 1997: 170: 281 284.AS EF F AM . Socio-economic aspects of khat in theHarrarghe administrative region, Ethiopia.Proceedings of the International Conference on Khat,Janua ry 17-21 1983, Antananarivo, Madagascar .BAASHERT, S ADOUNR. Epidemiology of khat.Proceedings of the International Conference on Khat,Janua ry 17-21 1983, Antananarivo, Madagascar .B A L I N TA , GEBREKIDAN, B A L I N TE . uthu edulis, a ninternational socio-medical problem with considerablepharmacological implications. East Afr Med J 1991 68:555-561.K A L I X. Kh at: scientific knowl edge and policy issues. BrJ Addict 1987: 82: 47-53.

EL M I S. Khat consumption and problems in Somalia .Proceedings of the International Conference on Khat,Jan uar y 17-21 1983, Ant anana rivo, Mada gascar.KA LIX . The pharmacology of kha t . Gen Pharmacol1984: 15: 179-187.

Comparison of behavioural effects of cathinone,amphetamine and apomorphine. Pharmacol BiochemBehav 1984: 20: 181-184.K A LI X . Kh at: a pl ant with am phetamine effects. JSubst Abuse Tre at 1988: 5: 163-169.H A L B A C H. Medical aspects of chewing khat leaves.Bull World Health Organ 1972: 47: 21L29.M O R G H E MM , RU FAT I . Cul t iva tion and chewing ofkhat in the Yemen Arab Republic. Proceedings of theInternational Conference on Kh at, Janua ry 17-21 1983,

Antananarivo, Madagascar .GETAJIUN, K R I K O R I A ND. The economic and socialimportance of khat and suggested research and services.Proceedings of the International Conference on Khat,Jan uar y 17-21 1983, Ant anana rivo, Madag ascar.E R I K S S O NM , GHANI A, KRISTIANSSON. K h a tchewing during pregnancy: effect upon the off-springand some characteristics of the chewers. East Afr Med J1991: 68: 106-110.E L - S H O U R AM , A B D ~ L ZIL M, AL I ME, e t a l .Deleter ious effects of khat addiction on sperm para-meters and sperm ultra-structure. H u m Reprod 1995:

SCHECHTER M D , RO SE C R A N SA , G L E N N O N A .

10: 2295-2300.

90




16. KENNEDY, TEAGUE, RROKAW, COONEY. A medicalevaluation of the use of qat in North Yemen. SOCSciMed 1983: 17: 783-793.

17. MEKASHA. The clinical effects of khat Catha edulisForsk): Proceedings of the International Symposium on

Khat, December 15 1984, Addis Ababa, Ethiopia.18. YOUSEF, HUQZ, LAMBERT. Khat chewing as a causeof psychosis. Br J Hosp Med 1995: 99: 322-326.

19. PANTELIS, HINDLERG, TAYLORC. Use and abuse of

khat Catha edulis): a review of the distribution,pharmacology, side effects and a description ofpsychosis attributed to khat chewing. Pharmacol Med1989: 19: 657-668.

20. GIANNINIJ, CASTELANIS. A manic like psychosis dueto khat Catha edulis Forsk.). J Toxicol Clin Toxicol1982: 19: 455459 .

21. GOUGHP, COOKSONB. Khat induced schizophreniformpsychosis in the UK (letter). Lancet 1984: 1: 455.

22. DHADPHPALE, MENGECH NK, CHEGE W. Miraa(Catha edulis) as a cause of psychosis. East Afr Med J1981: 58: 130--135.

23. ALEMA, SHIBBE . Khat induced psychosis and itsmedico-legal implication: a case report. Ethiop Med J1997: 35: 137-141.

24. GEBREELASSIE GE BRE . Rapid assessment of thesituation of drug and substance abuse in selected urbanareas in Ethiopia. Addis Ababa: Ministry of Health,1995.

25. ZEINAZ. Poly drug abuse among Ethiopian Universitystudents with particular reference to khat Catha edulis).Am J Trop Med Hyg 1988: 91: 1-5.

26. ADUGNA, JIRAC, MOILAT. Khat chewing amongAgaro Secondary School students, South WesternEthiopia. Ethiop Med J 1994: 32: 161 166.

27. ALEM , JACOBSSON, ARA YA , KEBEDE, KULLGRENG. How are mental disorders seen and where is help

sought in a rural Ethiopian community? A keyinformant study in Butajira, Ethiopia. Acta PsychiatrScand 1999: 100 (Suppl): 4 047 .

28. ALEMA, KEBEDE , WOLDESEMIAT, JACOBSSON,KULLGREN. The prevalence and socio-demographiccorrelates of mental distress in Butajira, Ethiopia. ActaPsychiatr Scand 1999: 100 (Suppl): 48-55.

29. OMOLO E, DHADPHALE. Alcohol use among khatCatha edulis) chewers in Kenya. Br J Addiction 1987:

82: 97-99.30. MIATAI CK . Epidemiology. Proceedings of the

International Conference on Khat, January 17-211983, Antananarivo, Madagascar.

31. MIATAI K. Country report; Kenya. Proceedings of theInterna tional Conference on Khat, January 17--21 1983,Antananarivo, Madagascar.

32. SEYOUM , KID ANE , GER RUH, SEVENHUSEN.Preliminary study of income and nutritional statusindicators in two Ethiopian communities. Food NutrBull 1986: 8: 3741 .

33. OMOLO E, DHADPHALE. Prevalence of khat chewers

among primary health clinic attenders in Kenya. ActaPsychiatr Scand 1987: 75: 318-320.

34. DHADPHALE, OMOLOE. Psychiatric morbidity amongkhat chewers. East Afr Med J 1988: 65: 355-359.

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The Prevalence of Chat Chewing in Butajira