Psychoactive substance use among first-year students in a Botswana University: Pattern and demographic correlates

Abstract

Background:
Substance use amongst university students is a recognized problem worldwide. Few studies have been carried out in this group in Botswana. These studies have been mostly limited to the use of alcohol and tobacco. Therefore, this study was designed to investigate the pattern of general substance use, its association with psychological distress and common socio-demographic factors among first-year undergraduates in a Botswana University.

Methods:
A total of 401 students were interviewed using a modified W.H.O. student drug use questionnaire and the 12 item General Health Questionnaire (GHQ12) to assess the pattern of psychoactive substance use and its relationship with psychological distress amongst university students in Botswana.

Results:
Alcohol was the most (31.9%) commonly used psychoactive substance. Age of debut for most psychoactive substances was between the ages of 15-18 years. Current use of alcohol (p = 0.045), amphetamine-type stimulants (p = 0.004) and benzodiazepines (p = 0.021) were associated with significant psychological distress. A positive relationship was observed between low participation in religious activities and substance use (OR = 4.63, 95%CI: 2.03-10.51), while a negative association was observed between not having a friend who uses drugs and substance use (OR = 0.44, 95%CI: 0.19-0.99).

Conclusions:
There is a significant substance abuse problem in the undergraduate population in Botswana. Our findings followed the global trend, with alcohol being the most commonly used substance. Religious participation demonstrates potential to be one of the solutions to this problem, but how to harness its seemingly protective influences is a field for further study.

Full text

R E S E A R C H A R T I C L E Open Access
Psychoactive substance use among first-
year students in a Botswana University:
pattern and demographic correlates
Anthony A. Olashore
1*
, Olorunfemi Ogunwobi
2
, Eden Totego
3
and Philip R. Opondo
1
Abstract
Background: Substance use amongst university students is a recognized problem worldwide. Few studies have
been carried out in this group in Botswana. These studies have been mostly limited to the use of alcohol and
tobacco. Therefore, this study was designed to investigate the pattern of general substance use, its association with
psychological distress and common socio-demographic factors among first-year undergraduates in a Botswana
University.
Methods: A total of 401 students were interviewed using a modified W.H.O. student drug use questionnaire and the 12
item General Health Questionnaire (GHQ12) to assess the pattern of psychoactive substance use and its relationship with
psychological distress amongst university students in Botswana.
Results: Alcohol was the most (31.9%) commonly used psychoactive substance. Age of debut for most psychoactive
substances was between the ages of 15–18 years. Current use of alcohol (p= 0.045), amphetamine-type
stimulants (p= 0.004) and benzodiazepines (p= 0.021) were associated with significant psychological distress. A
positive relationship was observed between low participation in religious activities and substance use (OR = 4.63,
95%CI: 2.03–10.51), while a negative association was observed between not having a friend who uses drugs and
substance use (OR = 0.44, 95%CI: 0.19–0.99).
Conclusions: There is a significant substance abuse problem in the undergraduate population in Botswana. Our
findings followed the global trend, with alcohol being the most commonly used substance. Religious participation
demonstrates potential to be one of the solutions to this problem, but how to harness its seemingly protective
influences is a field for further study.
Keywords: Substance use, Risk factors, Psychological distress, University students, Botswana
Background
For several centuries, psychoactive substances have been
widely used all over the world for various reasons. Alco-
holic beverages for example, have played significant so-
cial, economic, political, and traditional roles in many
civilizations in Europe, America, and Africa [1]. Several
other psychoactive substances have been used in soci-
eties for one medicinal purpose or the other. Cannabis
use for its medicinal properties is believed to have
started in China over 4000 years ago [1].
Despite the medicinal benefits of some psychoactive
substances and their social acceptability, they are related
to some undesirable health, social, legal and economic
outcomes [2]. Tobacco accounts for 8.8% (4.9 million)
deaths and 4.1% (59.1million) of Disability Adjusted Life
Years (DALYs), while illicit drugs such as opioids, 0.4%
of deaths and 0.8% of DALYs [2]. Of concern is the in-
creasing relationship between HIV/AIDS infection, vio-
lence and substance abuse. In Botswana, heavy use of
alcohol has been found to be associated with higher
odds of all risky sex behaviors, gender-based violence
and HIV transmission in both genders [3]. Furthermore,
the relationship between substance use and psycho-
logical distress has been demonstrated using the General
* Correspondence: olawaleanthonya@gmail.com
1
Department of Psychiatry, University of Botswana Medical School, Private
Bag, 00712 Gaborone, Botswana
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Olashore et al. BMC Psychiatry (2018) 18:270
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Health Questionnaire (GHQ) and other psychological
instruments [4,5].
Initiation to substance use mostly starts between the
ages of 12 and 24 years and males are more susceptible
than females, although this gap narrows as the age of
initiation increases [4,6]. The usual ages of entry into
the university especially in this part of the world coin-
cide with the ages of drug initiation, and for some
youths, their first contact is during their university edu-
cation. University life especially the early part has been
described as a “transitional”period during which stu-
dents move from a restricted high school life, mostly su-
pervised by parents, to a more independent life which
may be readily influenced by a liberal campus environ-
ment [7]. Some other factors that may predispose to
drug use among undergraduates include academic pres-
sure, peer pressure, easy accessibility, and unhealthy
family background [8]. Alcohol and tobacco are often
the first to be initiated of all the psychoactive substances
[6,9]. Alcohol is the most widely used psychoactive sub-
stances across the globe, accounting for 90.8% [9]. Ex-
cept for the United States of America, Brazil, Mexico,
Denmark and Spain where cannabis use ranked second,
tobacco is the second most commonly consumed drug
in most countries [9]. Studies conducted among univer-
sity undergraduates from different parts of Africa gave
similar results [4,10].
Previous studies conducted in Botswana have only re-
ported on the use of alcohol and tobacco [11–13], which
may lead to an erroneous assumption that these are the
only drugs abused. Nonetheless, the fact that tobacco
has been regarded as a gateway drug [14] suggests the
existence of use of other unreported psychoactive sub-
stances. To explore this, we set out to investigate the
pattern of substance use, its association with psycho-
logical distress, and common socio-demographic factors
among undergraduates, using an instrument that mea-
sures a broader range of drugs. This study will not only
add to the existing knowledge and provide a broader
picture of substance use but should also identify areas
for further research on drug use in Botswana.
Methods
The study was a cross-sectional descriptive study which
assessed substance use among full-time first-year stu-
dents of a tertiary institution in Botswana. The mini-
mum sample size required was 373, but the research
instruments were administered to 410 students based on
the calculated minimum sample size with an additional
10% allowance for non-response.
The sampling method and procedure for distribution of
questionnaires involved a multi-stage sampling technique
(i.e., selection done in stages from faculties through de-
partments until the final sampling units were arrived at).
In the first stage, five faculties out of the existing seven
faculties were selected by simple random technique
(balloting). In the second stage, eight departments were
randomly selected from 5 faculties, with one department
each from two faculties and two from the remaining three
selected faculties which have more departments. In the
third stage, about 51 respondents were selected from
first-year students in each of the preselected departments.
This study was conducted after obtaining ethical ap-
proval from the University of Botswana Research and Eth-
ical Review Committee. The approval to embark on the
study was given based on the assurance that the name of
the study site (institution) would not be used in the publi-
cation. A written informed consent was also obtained
from everyone who agreed to participate in the study.
Two research instruments were used for the present
study. The first consisted of a modified version of the 37
item World Health Organization (WHO) drug question-
naire. The WHO developed the prototype in conjunc-
tion with the United Nations Division of Narcotics; the
International Narcotics Control Board and the Inter-
national Council on Alcohol and Addictions. It was de-
signed to aid in epidemiological data collection on drug
abuse across different geographical regions of the world,
and it is recommended for use among students and
other populations. Items in the questionnaire consist of
different types of psychoactive/illicit substances, such as
Cannabis, cocaine, hallucinogens, opioids, and sedatives.
Specific examples relevant to this environment were
given for the classes of drugs for simplicity. For example,
drugs such as methylphenidate (Ritalin), khat, and
crystal-meth were cited in the case of amphetamine-type
stimulants (ATS). Participants were also asked to include
other forms of drugs not listed in the examples. It mea-
sures the lifetime, 12-month and current use (i.e., in the
last 30 days) of these psychoactive substances. It also
consists of relevant questions on the socio-demographic
characteristics of the respondents such as age, religious
participation, ethnicity, position in the family, parents’
marital status, parents’level of education and occupa-
tion. Religious participation was measured by frequency
of attendance of religious activities, where a subjective
response of “never”or “rarely”were grouped as poor
participation and “regularly”as good participation. A fic-
tional drug ‘maladrine’was added to the list of psycho-
active substances. Those who agreed to have taken this
fictional substance were excluded from further analysis
to reduce the bias of over-reporting.
The second instrument comprised of the 12-item Gen-
eral Health Questionnaire (GHQ −12), was used to assess
the presence of psychological distress in the students. The
GHQ-12 is a 12 item screening device for identifying
minor psychiatric disorders in the general population and
is suitable for adolescents and young adults. It has been
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found to have good internal consistency across many cul-
tures as reflected by Cronbach’s alpha range from 0.82–
0.89 in regions as diverse as Africa, Asia, Europe and
South-America [15–17]. Each question has four possible
responses; the respondent was asked to choose only one
response which best fits how he/she felt recently. The first
two responses were scored “0”while the last two were
scored “1”each. A score of 1 on each item was considered
positive and a score of 0, negative. Positive scores were indi-
cative of psychological distress. The cut-off of 3 was derived
from the calculated GHQ mean score; hence, a score of 3
or more was used in this study to indicate psychological
distress as in a previous study in a similar setting [4].
Data Analysis was done using the Statistical Package
for Social Sciences (SPSS for Windows), Version 16. Fre-
quency tables were employed for descriptive statistics
such as the socio-demographic variables and prevalence
of drug use. Cross-tabulations were done to show the
prevalence of substance use by gender, and the relation-
ships between substance use and GHQ score. A bivariate
analysis was performed to explore the relationship be-
tween identified socio-demographics and current use of
any substance. To further explore this relationship, the
significant variables on bivariate analysis were entered
into a binary logistic regression, with current use of any
substance as the dependent variable. Fishers Exact Test
(FET) was used where applicable. The level of statistical
significance for all tests was set at p< 0.05.
Results
Socio-demographic characteristics of the respondents
Out of 410 students interviewed, only 401 (97.8%) re-
sponses were analyzed. The remaining nine were excluded
for admitting to the use of fictional drug, ‘maladrine,’that
was intentionally included to forestall over-reporting, and
for incomplete responses. The mean age of the respon-
dents was 20.8 (SD =1.4) years, while the age range was
18–24 years. More female students (50.4%) participated in
the study than males (49.6%). Over half (58%) of the par-
ticipants came from the Tswana ethnic group. Christianity
was the most predominant religion (63.6%), followed by
African traditional religion (18.9%), and others (8.8%),
such as Hinduism and Buddhism. More than two-thirds
of the respondents participated regularly in religious activ-
ities and received monthly allowance below150 USD
(Table 1).
Prevalence and pattern of drug use
The lifetime prevalence of any substance use (defined as
at least a single episode of use) was 59.6%, 12-months
prevalence (previous year) was 49.4% while the current
use was 37.9%. The lifetime prevalence of multiple drug
use, technically defined as the use of more than one psy-
choactive substance, was 45.1%, 12-months (previous
year) was 42.4% and current use 36.4%. Alcohol was the
most commonly used psychoactive substance with 31.9%
current users. Of these, beer (51.5%) and wine (26.6%)
were the most frequent types. This was followed by
tobacco which was 18.7% and cannabis, 6.2% (Fig. 1). In-
halants, which were majorly in the form of petrol and
glue, were 3.2%. ATS, which comprised of methylphen-
idate, street drugs, crystal meth, and khat were 3.7%,
while controlled drug such as benzodiazepines was 1.1%.
Except for inhalants (FET, p< 0.01), no gender difference
was observed in the rates of psychoactive substance use.
Majority of the psychoactive substances were first tried
between the ages of 15–18 years. None of the illegal
drugs (cocaine, cannabis, heroin, and codeine) uses
started before the age of 11 years, but most of those who
use inhalants or solvents such as petrol started at the
age of 10 (Table 2).
Table 1 Socio-demographic characteristics of the respondents
Variable Statistic
Age, years; mean (sd) 20.8 (1.4)
Age range 18–24 years
Frequency N Percent
Age group
a
391 100
< 21 years 219 56.0
21–25 years 164 41.9
> 25 8 2.0
Gender 401 100
Male 199 49.6
Female 202 50.4
Religion
a
396 100
Christianity 252 63.6
Islam 11 2.8
Traditional religion 75 18.9
Others 35 8.8
No religious affiliation 23 5.8
Religious participation 389 100
Rare or low religious participation 89 22.9
Regular participation 300 77.1
Ethnicity 393 100
Tswana 229 58.3
Kalanga 122 31.0
Others 15 3.9
Foreigners 27 6.9
Monthly Upkeeps
a
347 100
Below 130 USD 97 28.0
130–150 USD 199 57.3
Above 150 USD 51 14.7
a
N =n not equal to 401 due to missing data
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Drug use and psychological distress
About 16% of the students had significant psycho-
logical distress, (defined as GHQ score of 3 and
above). Current use of alcohol (χ
2
=4.03, p= 0.045),
ATS ( χ
2
= 8.35, p= 0.004) and benzodiazepines (FET,
p= 0.021) were associated with significant psycho-
logical distress. Similarly, lifetime use of benzodiaze-
pines (FET, 0.005) and codeine (FET, 0.045) were
associated with GHQ of 3 and above (Table 3).
Factors that were associated with any substance use
among university undergraduates
Factors that were significant on bivariate analysis were age
20 years and below (χ
2
=7.34, p= 0.007), poor participa-
tion in religious activities (χ
2
=33.8, p< 0.01), earning 150
USD and above per month (χ
2
=6.20, p= 0.013), having a
father who smokes cigarette (χ
2
=6.81,p= 0.009), having a
father who drinks alcohol (χ
2
=19.5, p= < 0.01), and hav-
ing a friend who uses drugs (χ
2
=6.57,p=0.010)(Table4).
With logistic regression analysis, only two of these vari-
ables were found to have significant relationships with any
substance use. Poor participation in religious activities was
positively related with any substance use (OR = 4.63,
95%CI: 2.03–10.51), not having a friend who uses
drugs was negatively associated with any substance
use (OR = 0.44, 95%CI: 0.19–0.99) (Table 5).
Discussion
Drug use among undergraduates is as noteworthy a prob-
lem in Botswana as elsewhere [8,18–20] and has mainly
Fig. 1 Showing the prevalence of psychoactive substance use among respondents. LSD - Lysergic acid diethylamide. ATS - Amphetamine-type stimulants
Table 2 Age at first use of drugs among respondents
Age at first drug use in years, n (%)
Drugs Frequency
(N)
10 or
less
11–14 15–18 19 or
more
Tobacco 120 6 (5.0) 24 (20.0) 54 (45.0) 36 (30.0)
Alcohol 200 14 (7) 17 (8.5) 93 (46.5) 76 (38.0)
Cannabis 45 –3 (6.7) 20 (44.4) 22 (48.9)
Cocaine 4 ––3 (75.0) 1 (25.0)
ATS 33 5 (15.2) 2 (6.1) 8 (24.2) 18 (54.5)
Inhalants 17 11 (64.7) 3 (17.6) 1 (5.9) 2 (11.8)
Benzodiazepines 6 1 (16.7) 1 (16.7) 1 (16.7) 3 (50.0)
Heroin 1 –1 (100) ––
Codeine 6 –1 (16.7) 3 (50.0) 2 (33.3)
LSD 1 –––1 (100)
LSD lysergic acid diethylamide, ATS Amphetamine-type stimulants
Table 3 Respondents’drug use and GHQ score
Drugs GHQ score
GHQ (0–2) N (%) GHQ (3–12) N (%) χ
2
p
Tobacco
Current use 60 (87.0) 9 (13.0) 1.64 0.200
Alcohol
Current use 104 (87.4) 15 (12.6) 4.03 0.045
Cannabis
Current use 17 (70.8) 7 (29.2) 1.99 0.158
Cocaine
Current use 3 (100) –0.99
ATS
Current use 8 (53.3) 7 (46.7) 8.35 0.004
Inhalants
Current use 11 (91.7) 1 (8.3) 0.82 0.360
Benzodiazepines
Current use 1 (25.0) 3 (75.0) 0.021
*
ATS amphetamine-type stimulants
*
FET = Fisher’s Exact Test. Significant p- value in italics
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Table 4 Bivariate analysis showing the relationship between identified risk factors and any substance use
Variables Any Substance use Statistic
No yes
N(%) N(%) df χ
2
P
Age (years) 149 (68.0) 70 (32.0) 1 7.34 0.007
20 and below 94 (54.7) 78 (45.3)
Above 20
Ethnicity
Tswana 143 (62.4) 86 (37.6) 4 7.46 0.059
Kalanga 78 (63.9) 44 (36.1)
Others 12 (80.0) 3 (20.0)
Non-citizens 11 (40.0) 16 (59.3)
Religion
No religious affiliation 15 (65.2) 8 (34.0) 4 1.18 0.881
Christianity 152 (60.3) 100 (39.7)
Islamic religion 7 (63.6) 4 (36.4)
African traditional religion 48 (64.0) 27 (36.0
Others 24 (68.6) 11 (31.4)
Religious participation
Rare or low religious participation 32 (36.0) 57 (64.0) 1 33.8 < 0.01
Regular participation 210 (70.0) 90 (30.0)
Upkeep/month
Below 150 USD 71 (73.2) 26 (26.8) 1 6.20 0.013
150 USD and above 147 (58) 103 (41.2)
Father’s level of education
Below secondary school 45 (67.2) 22 (32.8) 1 0.104 0.747
Secondary school and above 130 (65.0) 70 (35.0)
Mother’s level of education
Below secondary school 52 (58.4) 37 (41.6) 1 0.68 0.409
Secondary school and above 181 (63.3) 105 (36.7)
Father’s employment status
No employement 43 (63.2) 25 (36.8) 1 0.043 0.835
Employed 137 (64.6) 75 (35.4)
Marital status of the parents
Divorced 46 (58.2) 33 (41.8) 2 2.13 0.350
Married and staying together 112 (66.7) 56 (33.3)
Separated or never married 71 (60.2) 47 (39.8)
Father smoking cigarette
No 112 (72.7) 42 (27.3) 1 6.81 0.009
Yes 52 (56.5) 40 (43.5)
Father drinking alcohol
No 91 (77.8) 26 (22.2) 1 19.5 < 0.01
Yes 71 (51.1) 68 (48.9)
Mother smoking cigarette
No 218 (62.5) 131 (37.5) 1 0.28 0.594
Yes 6 (54.5) 5 (45.5)
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been underreported. The present study, to our know-
ledge, was the first to determine the pattern of general
drug use among university students in Botswana. The
lifetime prevalence for any substance use was 59.6%;
12-month prevalence was 49.4% while the current use
was 37.9%. These figures are within the range described in
previous literature from the developed countries [9,20,21]
and are similar to those found in Africa as well. For ex-
ample in West Africa, the lifetime prevalence of any sub-
stance use ranged from 56 to 78% and 1-month prevalence,
28–40% among undergraduates [4,8].Therewasahigh
prevalence of multiple drug use among the respondents
with 36.4% currently engaging in multiple drug use. Mul-
tiple drug use has been associated with higher rates of
complications including rule-breaking behavior [22], sexual
and physical abuse [3], and various other psychiatric disor-
ders [5]. This relationship is complex and multidirectional.
While this present study did not set out to assess the rela-
tionships between drug use and anti-social or high-risk be-
haviors, the finding of a high prevalence of multiple drug
use may be an indication that this population is a high-risk
group for complications of drug abuse.
As in many other studies on drug use in youths [4,9,20],
alcohol was the most commonly used psychoactive sub-
stance with a current prevalence of 31.9%. The significant
role of alcohol in many social functions, its wide availability
and the social acceptability of its use, are reasons that
have been adduced for this trend [8]. Production of
alcohol (mostly from Sorghum) and its consumption
has been an integral part of the culture and village
life in Botswana, but consumption of alcoholic beverages
was traditionally restricted to elders of the community
[23]. Rapid industrialization and economic globalization
have brought about sudden and extensive social transfor-
mations in the developing countries, including Botswana.
Children and women who were previously excluded from
drinking now constitute a significant proportion of con-
sumers of these products [23]. However, our study re-
vealed a lower prevalence than what was previously
reported in Botswana, 58% [13], 44.4% [12] and Nigeria,
58% [4] among undergraduates. While we cannot make a
direct comparison between the current study and the pre-
viously conducted studies in Botswana, it is possible that
the 30% tax placed on its purchase is playing a significant
role in the reduction of alcohol consumption in Botswana,
as suggested by previous authors [24].
Tobacco was the next most commonly used psycho-
active substance in this study group as reported else-
where [4,9,20] with a current prevalence of 18.7%. This
rate is much higher than the prevalence reported in the
Global youth tobacco surveillance report from 2000 to
2007 (9.5%) [25] but similar to the rates from Europe
(19.2%) and America (15%) [25]. The rate reported in
this study is also lower than what was previously re-
ported among teachers in Botswana. Although, the low
prevalence among the teachers could have been related
Table 4 Bivariate analysis showing the relationship between identified risk factors and any substance use (Continued)
Variables Any Substance use Statistic
No yes
N(%) N(%) df χ
2
P
Mother drinking alcohol
No 203 (63.6) 116 (36.4) 1 0.78 0.378
Yes 22 (56.4) 17 (43.6)
Friend using any substance
No 200 (64.3) 111 (35.7) 1 6.57 0.010
Yes 34 (47.9) 37 (52.1)
Significant p-value in italics
Table 5 Logistic regression showing the factors that are associated with substance use among students
Variables Statistics
95% Confidence Interval
Wald p-value OR lower upper
Age (20 years and below) 0.10 0.757 1.11 0.57 2.19
Rare or low religious participation 13.4 < 0.001 4.63 2.03 10.51
Earn below 150 USD per month 0.04 0.851 0.93 0.43 1.99
Father does not smoke cigarette 0.53 0.467 0.75 0.35 1.61
Father does not drink alcohol 2.25 0.134 0.55 0.25 1.20
Does not have a friend abusing drug 3.96 0.047 0.44 0.19 0.99
Significant p-value in italics
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to Botswana legislation on tobacco control (Botswana
Control of Smoking Act, 1992), which strictly prohibits
any direct forms of tobacco advertising and use, it is
possible that youths are less likely to follow this law.
Moreover, only those who have recently completed their
first 1 year on campus were included in the present
study, and this may also explain the higher prevalence of
tobacco use in this sample. First-year students often face
significant challenges such as exposure to new courses,
more liberal campus environment, peer pressure, secur-
ing accommodation, which may stretch their capacity to
cope and engender substance use behavior. Among
youths, alcohol and tobacco have been referred to as
“soft drugs”taking into consideration that they are legal
in most countries and also as “gateway drugs,”based on
the trend of being the first psychoactive substance taken
by many users before “graduating’to other psychoactive
substances [14]. The respondents in our study seem to
maintain that pattern. It is, therefore, necessary to set up
policies and programs targeted towards controlling the
use of these “soft drugs”and prevent the progression to
more dangerous drugs.
Consistent with the findings of the global report, can-
nabis was the most commonly used illicit substance with
9.2% admitting to using the substance within the last
12 months and 6.2% current users. The rate of those
who have used the substance in the last 12 months is
similar to what has been reported by previous authors
from other countries [4,10,19,21]. Nevertheless, the rates
of other illicit and prescription drugs such as cocaine, co-
deine, ATS, and benzodiazepines are quite low as in other
studies from Africa [4,19], but unlike in the United States,
where their uses have been reported to be on the increase
[18,20]. As in other African countries, it is possible that
these substances are too expensive to procure and sustain
in Botswana, especially by these individuals who mostly
survive on stipends from the government.
It is important to note that, apart from inhalant use which
was mainly a male-dominated affair, no gender difference
was observed in the use of other substances. These findings
suggest that drug use is not an entirely male-dominated
activity in Botswana. Conversely, gender-based roles pre-
scribed for women are protective against drug abuse behav-
iors in many communities [4,23]. Men have been reported
to be more likely to use tobacco and other illicit substances
than women [4,20,22].Perhaps,thenatureofoursampleis
responsible for this disparity. In Botswana, due to the
adoption of western social norms particularly amongst
urban youths, there is a little cultural restriction against the
use of psychoactive substances by females. This is evidenced
by the open consumption of alcohol and tobacco without
any apparent social censure. This practice is entirely differ-
ent from some other regions in Africa, where such habits
are deemed socially unacceptable [4,26].
For most of the substances assessed the age range of
debut was 15–18 years. This finding may indicate a crit-
ical window period for drug abuse prevention programs
in the population. The substances which bucked this
trend included solvents such as petrol (aged 10 or less),
alongside ATS and benzodiazepines with a higher age of
debut (19 and above). As it has been previously docu-
mented, this finding suggests that inhalants may play a
role as a gateway drug as tobacco [27], and may require
specific attention in any drug abuse prevention programs
directed toward the pre-adolescent age group. The drugs
which had a relatively lower age of debut, i.e., alcohol,
tobacco, and inhalants are readily available in the com-
munity. Alcohol and inhalants are even more easily ac-
cessible for the pre-adolescents since alcohol is freely
available in many African households and inhalants such
as glue can be purchased without restrictions. Our find-
ing demonstrates that universal preventive techniques
that result in reduced availability and accessibility of
such substances may likely result in reduced consump-
tion and abuse of the substances. In addition to the tax
and restriction of alcohol and cigarette sales to
under-18’s, parents should also be educated on how to
prevent access to these substances at home. Perhaps
there should also be a restriction on sales of inhalants to
children less than 18 years, as in alcohol and tobacco.
There is increasing evidence suggesting that a lower age
of debut is associated with a higher rate of problems
with drug use ranging from dependence, other
drug-related disorders to delinquency [6], and other
mental disorders [5]. Thus, no effort should be spared in
preventing minors from experimenting with psycho-
active substances.
Current use of either alcohol or ATS was seen to be
significantly associated with psychological distress in the
current study. It is imperative to note that, the direction
of the correlation cannot be assumed due to the
cross-sectional nature of this study. Perhaps, the psycho-
logical distress contributed to or led to substance use,
and not vice-versa. This assumption deserves further in-
vestigation. Even so, it has been established that despite
the social acceptability of alcohol use, it still presents a
public health concern. It is estimated that about 4% of all
deaths worldwide are attributable to alcohol consumption
along with 4.5% of the global disease and injury burden
[28]. For example in Botswana, alcohol-impaired road
traffic crashes are one of the leading causes of disabilities
and deaths [24]. The impact of alcohol consumption on
public health statistics cannot be overstated. There is a
need to reduce alcohol accessibility and availability to ado-
lescents. There may also be the need to make policies on
the attractiveness of the packaging and to limit advertise-
ments of alcoholic products similarly as it is being done
for tobacco. The use of benzodiazepines and codeine were
Olashore et al. BMC Psychiatry (2018) 18:270 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

also significantly associated with psychological distress, al-
beit these findings should be interpreted with caution due
to the sample size. These “Central Nervous System de-
pressants”are in most cases prescription drugs diverted
for recreational purposes through self-medication. These
drugs are already highly regulated. There is, therefore, a
need to enforce the existing regulations and improve them
where necessary.
On bivariate analysis, participants whose fathers were
not using any psychoactive substance (alcohol or to-
bacco), and those who live on less than 150 USD per
month were less likely to use drugs. Studies have shown
that parental substance use is a factor in substance use
among their offspring [29]. For example, Kilpatrick et al.
found an increased risk of substance abuse in adoles-
cents who had family members with alcohol or drug use
problem [30]. In the same vein, smoking in adolescents
has been found to be associated with lower family socio-
economic status [31]. Cigarettes are cheaper and more
accessible for students with little financial resources.
Despite these finding, these variables, including age
groups failed to predict psychoactive substance use in
our sample on logistic regression.
Logistic regression showed that poor participation in
religious activities was positively correlated with sub-
stance use while not having a friend who uses drugs was
negatively correlated. This finding has been shown in
studies elsewhere [32,33]. In a study conducted among
12595 Brazilian university students, frequent participation
in religious activities was shown to have a protective ef-
fect against substance use [32]. It is possible that partici-
pation in religious activities provides opportunities to
interact with non-drug using peers. Since peer influence
is at peak during adolescence [34], the negative correl-
ation between not having a friend who uses drugs and
substance use is thus not surprising. Peer group influ-
ence has been shown to be a factor in substance use [35]
whereas, religious students have also been noted to be
less prone to engage in risky behavior [36] such as drug
abuse. How to harness these seemingly protective influ-
ences is a field for further study.
Conclusions
There is evidence that the use of psychoactive sub-
stances is a problem in the undergraduate population in
Botswana. The most commonly used psychoactive sub-
stance was alcohol as elsewhere, but the government
30% tax policy on alcoholic beverages may have contrib-
uted to the relatively lower rate in the current study.
There is a high rate of the early debut of inhalants, to-
bacco, and alcohol, which is possibly driven by their
availability to pre-adolescents mainly. Poor participation
in religious activities was positively correlated with sub-
stance use while not having a friend who uses drugs was
negatively correlated. The role of religious participation
in addressing drug abuse on campus should be further
explored.
Recommendations
This study has demonstrated that there is a significant
problem of drug use amongst youths in Botswana and it
suggests a need for urgent action to reverse the trend.
Proper orientation package should be designed for fresh
students to enable them to adjust and adapt to the new
stage of life very easily. School health policies should be
adjusted to include programmes targeted towards drug
education and counseling. Participation in religious ac-
tivities appears to plays an important role in inhibiting
the use of a psychoactive substance. Therefore, a condu-
cive environment which encourages religious activities,
and other adaptive ways of relieving stress should be en-
couraged in the university community.
Limitations and strengths
The study was conducted in one tertiary institution and
may not be generalizable to the entire adolescent popula-
tion of Botswana, particularly in the context of relatively
low university enrolment. It was also cross-sectional de-
scriptive and may not be able to determine causality of
any of its findings. It is, however, the first to look at sub-
stance use generally and not a specific or few substances.
It also attempted to see a relationship between substance
use and the associated problems of psychological distress.
Future research
It will be necessary to conduct a similar study in the gen-
eral youth population to see how the rates in this group
compare with the general youth population. It will be
helpful to assess the relationships between substance use
and other associated problems like criminal offending and
academic performance within this group and other similar
groups. The role of religious participation in addressing
drug abuse on campus should be further explored. There
is also a need to conduct a prospective study on drug
users particularly those with a lower age of debut to assess
the relationship of age of debut with outcomes.
Acknowledgements
Special thanks to the students who participated in the study and all the staff
who assisted in data collection.
Availability of data and materials
The datasets used and analyzed during the current study are available from
the corresponding author on reasonable request.
Authors’contributions
AAO developed the concept and designed the study. AAO and ET
conducted the data collection and analysis. AAO drafted the initial
manuscript. OO, ET, and PRO made substantial intellectual contributions to
the final manuscript. All authors read and approved the final manuscript.
Olashore et al. BMC Psychiatry (2018) 18:270 Page 8 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Ethics approval and consent to participate
Ethical approval was obtained from the University of Botswana ethical
committee (UBR/RES/IRB/1628). The purpose of the study was thoroughly
explained to every eligible participant, and a written informed consent was
obtained from everyone who agreed to participate in the study.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Psychiatry, University of Botswana Medical School, Private
Bag, 00712 Gaborone, Botswana.
2
Department of Psychiatry, Bowen
University Teaching Hospital, Ogbomosho, Nigeria.
3
University of Botswana
Medical School, Gaborone, Botswana.
Received: 27 March 2018 Accepted: 13 August 2018
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