PREVALENCE, FACTORS ASSOCIATED WITH AND PERCEIVED HEALTH
EFFECTS OF USE OF CANNABIS/ KHAT AMONG PERSONS AGED 18 YEARS
AND ABOVE IN MAKINDYE DIVISION, KAMPALA DISTRICT.
KASULE HAFISA, MB Ch B
REG. NO: 2006/HD20/7612U
SUPERVISORS: 1. DR. KIWANUKA NOAH
2. DR.NALWADDA CHRISTINE
A RESEARCH DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE AWARD OF A DEGREE OF MASTER OF
PUBLIC HEALTH OF MAKERERE UNIVERSITY
NOVEMBER, 2011
DECLARATION
I, Dr. Hafisa Kasule do hereby declare that all the work presented in this dissertation is my
original work unless otherwise acknowledged. This work has never been submitted either in
part or in full for publication or award of a degree in any other university. I henceforth
present it for the award of the degree of Masters of Public Health of Makerere University.
Author
...........................................................
Date...............................................
Dr. Hafisa Kasule
.
Supervisors:
...........................................................
Date.................................................
Dr. Kiwanuka Noah
And
................................................. ..
Date..................................................
Dr. Christine Nalwadda
ii
DEDICATION
This book is dedicated to my father the late Ambassador Hajji Muhammad Kasule for his
passion about my education which has motivated me this far. I also dedicate it my husband
Mr. Kyambadde Muhammad for his encouragement.
iii
ACKNOWLEDGEMENT
My special thanks and gratitude go to my supervisors: Dr. Kiwanuka Noah and Dr. Nalwadda
Christine for their patience and invaluable guidance at all stages of this work; without which
this study would not have been completed. I also wish to thank the entire staff of MUSPH for
their support during the different stages of the Master of Public Health program.
I would also like to thank my study group members and colleagues: Mariam, Sarah, Sophie,
Yahaya, Hawa and Edison for their contribution towards my success throughout the course.
I Would like to thank my research assistants: Kabwama, Yusuf, Medi and Rose for their
commitment during data collection and management. I thank my research assistants for not
giving up when data collection was challenging in areas like Katwe parish where some the
residents were abusive.
I also extend my sincere thanks to Mr. Lule of Kampala city council, OC cid Katwe Police
Station former police inspector in charge of narcotics. I also appreciate the contribution of the
members of the focus groups, key informants and all respondents for their invaluable
informant which has contributed to this report immensely.
iv
TABLE OF CONTENTS
page
DECLARATION.........................................................................................................................i
DEDICATION............................................................................................................................ii
ACKNOWLEDGEMENTS........................................................................................................iii
LIS OF FIGURES AND TABLES.............................................................................................vi
ACRONYMS AND ABREVIATIONS.....................................................................................vii
OPERATIONAL DEFINITIONS…..……………….……………………… …….................viii
ABSTRACT……………….………………………….………………………..…......…...........xiii
CHAPTER 1. INTRODUCTION AND BACKGROUND…………………...….…..................1
1.1 Epidemiology of Substance Use ................................................................................................1
1.2 .4 Health effects on drug abuse.................................................................................................2
1.3 Background to the Study…………………………..…………………...…….........................3
CHAPTER 2. LITERATURE REVIEW…………..………………..…………............................4
2.1 Substance Abuse…………………………………………………….......................................6
2.2 Trends in the epidemiology of global drug use.........................................................................6
2.2.1 Consumption of cannabis.......................................................................................................6
2.2.2 Consumption of khat..............................................................................................................7
2.3 Factors contributing to use of drug use globally.......................................................................8
2.4 Health effects of abuse of drug abuse.....................................................................................11
2.4.1Health effects of cannabis.....................................................................................................12
2.4.2 Health effects of khat...........................................................................................................12
v
CHAPTER 3: STATEMENT OF THE PROBLEM, JUSTIFICATION, CONCEPTUAL
FRAMEWORK.........................................................................................................................12
3.1 Statement of the Problem.....................................................................................................12
3.2 Justification...........................................................................................................................13
3.3 Conceptual Framework for the use of khat and cannabis in Makindye division..................15
3.4 Study questions.....................................................................................................................17
CHAPTER 4: STUDY OBJECTIVES.......................................................................................18
4.1 General objective..................................................................................................................18
4.2 Specific objectives ...............................................................................................................18
CHAPTER 5: METHODOLOGY.............................................................................................19
5.1 Study area....................................................................................... ………….…….....…...19
5.2 Study population ..................................................................................................................19
5.3Study Design...........................................................................................................................19
5.4 Sample Size determination.....................................................................................................19
5.5 Eligibility criteria ...................................................................................................................19
5.5.1Inclusion criteria...................................................................................................................19.
5.5.2 Exclusion criteria.................................................................................................................19
5.6 Sampling procedure …………..…………......………………...............................................20
5.7 Study variables….....……….………………………………..................................................21
5.8 Data quality control ………….………………………………………...................................22
5.9 Data collection methods .......................................................................................................22
5.10 Data Management and analysis ………………………………...............................….. …..22
5.11 Ethical Considerations ............................................................................................ ............24
5.12Dissemination of results............................................................................................. ...........24
vi
CHAPTER 6: RESULTS................................................................................................... ..........26
6.1 Social- demographic characteristics of the study participants................................................26
6.2 Prevalence of use of cannabis and khat by people in Makindye division...............................27
3 6.3 Factors associated with use of khat and cannabis in Makindye division................................29
6.4 Assessment of participants knowledge about health effects of abuse of cannabis and
khat...............................................................................................................................................31
6.5 Bivariate Analysis...................................................................................................................32
6.6.1 Relationship between socio-demographic characteristics, other independent variables and
use of cannabis or khat..................................................................................................................33
6.7 Multivariable Analysis............................................................................................................36
6.7.1 Relationship between socio-demographic characteristics, other independent variables and
use of cannabis or khat..................................................................................................................36
CHAPTER 7: DISCUSSION......................................................................................................37
7.1 Prevalence of use of cannabis and khat by people in Makindye division...............................37
vii
7.3 Factors associated with use of khat and cannabis in Makindye division.......................37
7.4 Perception health effects of abuse of cannabis and khat................................................39
7.5 Study limitations............................................................................................................40
7.6 Conclusions....................................................................................................................40
7.7Recommendations...........................................................................................................41
REFERENCES....................................................................................................................42
APPENDIX 1: CONSENT FORM.....................................................................................46
APPENDIX 2: QUESTIONNAIRE FOR HOUSEHOLD PARTICIPANTS...................47
APPENDIX 3: KEY INFORMANT INTERVIEW GUIDE..............................................51
APPENDIX 4: FOCUSS GROUP DISCUSSION GUIDE...............................................52
APPENDIX 5: MAP OF MAKINDYE DIVISION...........................................................53
LIST OF FIGURES
viii
Figure 3.1: Conceptual framework for use of cannabis and khat.........................................11
Figure 6.1: Prevalence of cannabis/khat use in Makindye division....................................27
LIST OF TABLES
Table 6.1: Socio- Demographic characteristic of the study participants..............................26
Table 6 2: Frequency of consumption of cannabis and khat by current users.....................29
Table 6.3: Participants motivation for use or abuse cannabis and khat...............................30
Table 6.4: Problems for which respondents took drugs......................................................31
Table 6.5 Age at initiation of drug use.................................................................................32
Table 6.5: Assessment of knowledge on health consequences of khat and cannabis..........35
Table 6.6: Relationship between socio-demographic factors and the use of khat or cannabis
Table 6.7: Relationship between other factors and the use of khat or cannabis..................37
Table6.8:Unadjusted Odds ratio and adjusted odds ratio (OR) and 95% confidence
intervals (95%CI) of factors associated with use of khat or cannabis................................38
LIST OF ABBREVIATIONS
ix
ATS :
Amphetamine type stimulants
BC
Before Christ
:
DHO
District Health Officer
DHT:
District health team
DSM :
Diagnostic and statistical manual
EMCDDA;
European Monitoring Centre for Drugs and Drug Addiction
FGD:
Focus group discussion
IRB
Institutional Review Board
KCC:
Kampala City Council
KI:
Key informant
MOH:
M inistry of Health
MDG
Milleium Development Goal
NIDA
National Institute for Drug Abuse
UBOS:
Uganda Bureau of Statistics
UNDCP:
United Nations Drug Control Program
UNCST
Uganda National Council of Science and Technology
UNDP:
United Nations Development Program
UNESCO:
United Nations Education, Science and Cultural Organization
UNODC:
United Nations Office on Drugs and Crime
UNODCCP :
United Nations Office for drug control and crime prevention
WHO:
World Health Organization
x
OPERATIONAL DEFINITIONS
Substance or drug: all psycho active substances which when taken by living organisms
may modify its perception, mood, cognition, behaviour or motor function.
Division:
A geopolitical area demarcated under Kampala district and given
mandate to manage and deliver public services such as health
services to the public
Illicit drug:
These are substances whose possession is a criminal offence.
This study will focus on cannabis. Khat though not illicit is a
psychoactive substance prone to abuse and is commonly used in
Uganda.
Addiction:
The physical and psychological feeling of need to use a
substance in order to function. This comes with prolonged
repeated use of a substance
Substance abuse
A destructive pattern of substance use, leading to significant
social, occupational or medical impairments. The substances
considered in this study are cannabis and khat
Treatment
Provision of health services that treat illnesses brought by
substance abuse to its victims
Health effects
Victim
Current user:
All illnesses associated with substance abuse to its victims
Any person using and abusing khat or cannabis
Consumption of the drug at least once in the past 30days prior
to the study
Household:
Consumption of a substance at least once in one’s lifetime
Khat:
A group of people living together in a permanent or semipermanent or makeshift house and eat meals together
xi
Cannabis:
Khat is a stimulant drug derived from a shrub known as Catha
edulis
Cannabis is a term used to refer to the numerous psychoactive
preparations from the hemp plant, cannabis sativa. Cannabis is
Dependent
consumed in two major forms namely: the herb comprising of
variable :
leaves and flowering parts and hashish is a plant extract that is
usually smoked in special pipes.
Independent
variables :
the dependent variable in this study is use of cannabis/khat
-economic factors(income, unemployment, poverty)
-Social factors (living environment, peer influence, family
influence
-demographic factors(age ,sex religion, education area of origin
.
xii
ABSTRACT
Introduction: Use of cannabis/khat is public health problem that is believed to be rapidly
increasing worldwide. Uganda is one of the leading countries with big numbers of users of
cannabis/khat; with about 5 to 10% using alcohol, cannabis, khat and other drugs. In 2008,
2000 users of cannabis in Makindye Division were prosecuted and imprisoned. Makindye
Division, located in the South-Eastern Kampala, has got 21 parishes with 24% of the city’s
population. About 70% of Makindye’s population are low income earners.
Objective: To determine prevalence of, factors associated with and perceived health
effects of use of khat or cannabis among adults in Makindye division.
Methods: The study was a cross-sectional survey with 263 respondents selected by multi
stage random sampling and cluster sampling. The Makindye, the most populated Division
and 70% low income earners, was purposively selected. The parishes (clusters)
,zones/villages were randomly selected. Systematic random sampling of respondents was
used. Key informants were purposively selected from health workers, local council leaders
and police officers. Qualitative and quantitative methods of data collection were used. Data
were coded, cleaned and entered using EPIDATA and exported to STATA for analysis.
Data were presented in tables and bar chart. Multiple logistic regression model was used to
determine associations between the outcome and the independent variables. COR and
AOR were used to assess the strength of association. P-values and 95% CI were used to
determine significance of the association.
xiii
Results: Prevalence of cannabis/khat use was15.6%/ 34.6. About 75.7% of the respondents
were male. Adults<30years, low education level, family influence, use by friend, religion,
perception of health effects and living environment were associated with use of cannabis /khat.
About 62% of the respondents knew the major health consequences like.
Conclusion: The prevalence of cannabis/ khat use is 15.6%/34.6% in Makindye Division.
Cannabis/ khat use was associated with: Use of cannabis/ khat by family member, Use of
cannabis/ khat use by friend, Low education level. About 62% were aware of the main
health effects of cannabis/khat.
Recommendation: MOH and Kampala City Council Authority should design and
strengthen community prevention, programmes such to curb the use of khat/cannabis.
Deterrent laws against use of khat/cannabis should enacted and enforced.
.
xiv
CHAPTER 1: INTRODUCTION AND BACKGROUND TO THE STUDY
1.0 Introduction
1.1 Epidemiology of Substance Use
Substance abuse is one of the growing public health and social problem that has adversely
affected a significant proportion of population. According to UNODC (2008), 205 million
people are involved in substance abuse worldwide. Of these, 25 million people are
estimated to be problem drug users, many of whom are unable to stop without treatment.
Injecting drug users are estimated at 13.2 million worldwide. In Africa, substance abuse is
a public health problem reported to be on the increase since the 1970s (UNDP, 1997;
UNODC, 2008). WHO (2006) showed that while 17 to 42.8% of youths in Sub Saharan
Africa are involved in chronic excessive drinking of alcohol, those involved in abusing
drugs such as cannabis and others are 7 to 38%. Uganda is one of the leading countries
with big numbers of victims of use of cannabis/khat. In particular, MOH (2005) indicates
that 5 to 10% of Uganda’s population, estimated at 30 million people (UBOS, 2008), are
users of alcohol, cannabis, khat, aviation fuel, tobacco, amphetamine, pethidine among
others. Monthly reports of the Uganda Police, particularly the one of January 2010, indicate
that cannabis/khat abuse victims hunted down, arrested, convicted and imprisoned is
increasing in the country. Cases of users of cannabis / khat rising, especially in the slum
suburbs of Kampala district (Uganda Police, 2010). For instance in 2008, 2000 users
cannabis in Makindye Division were prosecuted and imprisoned (Katwe police, 2008).
Substance abuse refers to the use of a drug or other substances for non-medical purposes
with the aim of producing a mind-altering effect in the user (MOH, 2005). It involves the
use of illicit substances such as cannabis (marijuana) or licit ones like khat (Catha edulis ),
1
misuse of legal drugs or use of a drug or substances for purposes other than that for which
they are intended (MOH, 2005; Rehm & Eschmann, 2002).
There are many types of substances that are prone to abuse like alcohol, the most
commonly abused drug globally, hallucinogens such as cannabis and tobacco, hypnotics,
sedatives, anxiolytics and stimulants such as cocaine, caffeine, amphetamine and khat
among others. For purposes of this study, the researcher will focus on cannabis (marijuana)
and khat (Catha edulis)
1.2 Health effects of substance abuse
Worldwide, drug abuse is associated with serious health problems. The health effects are as
diverse as the drugs and also vary according to various factors namely: genetic predisposition, the
content of the active ingredients as well as environmental factors. For instance delta tetrahydro
cannabinol (δ-THC), the most active ingredient in cannabis, is believed to have receptors in the
brain affects the brain where its action is believed to cause delusions and hallucinations, and
memory loss. Cannabis is believed to increase the heart rate, decrease blood pressure, causes chest
infections and has been associated with lung cancer (Bradley 2011;NIDA 2010). On the other hand
khat is associated with insomnia, paranoid feelings, gastrointestinal problems and depression
(NIDA 2010, WHO 2010; Bitalkalamire, 2006).
Although the perceived health effects associated with use of cannabis /khat are serious, Uganda
does not have a specific law in place to deter people from using cannabis/khat. Users and sellers of
Cannabis are prosecuted under the Nation Drug Authority (NDA) act which refers to the use of
cannabis as drug misuse. This law is weak such that even when users and sellers are apprehended,
they are required to pay only Ug shs.100,000-200,000 as fine (Uganda Police2008; Kasirye, 2009).
2
According to Berkely (2009) khat use is technically legal in Uganda. Khat chewing has become a
new Ugandan leisure activity (Berkely, 2009).
Appropriate and effective strategies and programs need adequate information on patterns of use,
trends as well as the characteristics of users cannabis/khat. However available studies focus on
children both street and school going and do not highlight the prevalence of, factors associated
with use and the perceived of health effects resulting from use of khat / cannabis in Makindye
division hence this study.
.
1.2 Background to the Study area
Makindye Division is one of the five Divisions of Kampala City, the capital City of Uganda. It is
located in the South -Eastern part of Kampala District. It is bordered by Central and Lubaga
Divisions in the North-West, Mpigi District in the west, Lake Victoria and Mukono in the South.
Nakawa Division is found in the North- East of Makindye Division. Makindye Division covers a
total area of 40.7 hectares.
Administratively Makindye division is a local authority with the mandate to plan and budget under
decentralization. It is divided into 21 parishes. The hill tops of Buziga, Muyenga, Konge, Katuso
are inhabited by medium- to -high income groups while the parishes of Namuwongo, Wabigalo.
Kibuye and Katwe house the low income groups.
Makindye division is the most populated division, housing 24% of the city population
(UBOS,Population Census Report, 2002). According to the Kampala Urban Study (2005), the
3
population of Makindye division is 387,089. The population growth in Makindye Division is 5.2%.
This is mainly due to rural-urban migration.
Poverty is one of the major problems facing the people of Makindye Division especially the youth
and women. The majority of the population (70%) is comprised of low income earners. The people
engage predominantly in small-scale businesses, small scale industries, urban farming, fish
vending and small-scale service industries., communications, sale of alcoholic and non-alcoholic
beverages, commercial cycling, taxi driving and special hire; peddling, roadside vending, and a
variety of other business (Makindye Division Development Plan, 2005/06-2007/08).
The people of Makindye Division suffer from many diseases both communicable and noncommunicable. Non-communicable diseases associated with cannabis/khat like mental illness are
on the increase especially in the slums of Makindye Division (UBOS, 2006). However the
prevalence of, factors associated with and perceived health effects of use of khat /cannabis are not
known.
4
CHAPTER 2: LITERATURE REVIEW
Although information about the prevalence of substance abuse is abundant globally, that regarding
prevalence, associated factors perceived health effects of cannabis/khat use is relatively scanty,
especially in Makindye division, Kampala district. Thus, literature presented in this section is
largely cited from scholarly works outside Uganda. It is organized according to the variables of the
study.
2.1 Substance abuse
The term substance or drug refers to all psycho active substances –“any substances when taken by
a living organism may modify its mood perception, cognition behaviour or motor function”whether licit or illicit. According to the diagnostic
and statistical manual of the American
association,4th Edition(DSM-IV), substance abuse is a pattern of use which leads to clinically
significant impairment or distress as manifested by one or more of the following in a 12-mont
period(Wilson, 1999):

Recurrent substance use in
physically hazardous situations such as driving under
the influence of the substance

Recurrent substance use resulting in failure to fulfil major obligations at work, home
or school

Recurrent drug use leading to legal problem such as arrest for substance use ,related
disorderly conduct etc

Continued drug use despite having a persistent or recurrent social or interpersonal
problem caused or exacerbated by use of the substance
5
2.2 Consumption of cannabis
Cannabis is a term used to refer to the numerous psychoactive preparations from the hemp plant,
cannabis sativa. Marijuana is a Mexican term for cannabis leaves and other crude material of
cannabis. Other local and slang names include: njaga, weed, smoke and herb. It is usually smoked
as a cigarette or in a special pipe(hashish). It contains delta-9-tetrahydrocannibinol (THC) the main
hallucinogen that affects mood and perception. (MOH, 2005; WHO, 2006;WHO, 2010; Buddy
2011).The membranes of certain nerve cells in the brain contain THC receptors.
Worldwide, cannabis is the most widely cultivated, trafficked and abused illicit drug (WHO 2010;
NIDA 2010). Close to 147 million people, 2.5% of the world population consume cannabis
annually. In the Unite States of America, national surveys indicate that about one third of the adult
population has tried cannabis and 10% has used the drug in the previous twelve months
(NIDA2010; UNDCP, 1997; WHO, 2010) In most countries , rates of cannabis use are generally
higher in the young adults and in males than females. In the United Kingdom, lifetime prevalence
for adults is14% ,with rates of 24% among young adults (EMCDDA, 1996). Cannabis is the main
narcotic drug used by over 34 million people in Africa. (MOH, 2005; WHO, 2006; WHO,2010).
Studies conducted in Zimbabwe, Ghana, Nigeria, Ivory coast Ethiopia Kenya, Mozambique and
south Africa highlight cannabis use(UNODCCP, 1999). In some northern and sub –Saharan
countries like Egypt, Morocco, Nigeria and Tanzania there is a long tradition of cannabis use for
culinary , medicinal and ceremonial purposes. In the cape province of South Africa, a survey
conducted in 1990 found that 7.5% of high school students smoked cannabis (Flisher et al, 1993).
6
In Uganda, the anti narcotic police unit seized drugs weighing 13.67kilograms, worth 550 million
Uganda shillings between 2000 and 2004 (Uganda Police, 2004). Police in 2000, made 675 arrests
for possession of illicit drugs. The drugs seized were 6.2kg of cannabis and 54,700 cannabis plants
were destroyed (Uganda Police, 2000).
2.3 Consumption of khat (Catha edulis, mairungi).
Khat is a stimulant drug derived from a shrub, Catha edulis. Catha edulis is a white flowered
evergreen shrub found in East Africa and Arabia (NIDA, 2007). It has mildly narcotic properties
and its leaves are usually chewed. The main psychoactive ingredients are cathine and cathinone,
chemicals that are similar to amphetamines (NIDA, 2007). It has been used to treat various
ailments including depression (Glenice & Rampes, 2003)
Worldwide, it is estimated that 10millon people consume khat (NIDA, 2007). Studies show that
khat use differs by age, sex and occupation. For instance a large study in Yemen showed that 82%
men and 43% women reported one lifetime use of khat (NIDA, 2007). Another study in Ethiopia
showed that the prevalence of khat use was 50% (Belew, 2000). Ihunwo et al (2004) in a study
conducted in South western Uganda showed that khat use was highest among law enforcement
officials (97.1%) followed by transporters (9.2%) and students (8.8%).
2.3 Factors associated with global spread and use of drugs
In the 19th century, drugs tended to be available where they were produced or very close to the
source of production. The growth of transportation, tourism and communication in the 20th century
made transportation of goods including drugs and people easy across the world. In a study
7
conducted in south Africa (WHO/UNDCP, 2003) cannabis was reported to be easily accessible in
both rural and urban areas by 47% and 58% respondents respectively.
Studies further indicate that there are a number of social, economic and political factors associated
with the global spread and use of drugs. In particular, George & Milligan (2005) found that one of
the factors associated with substance abuse is family and community situations under which people
are raised. Lack of parental affection, high levels of harsh criticism and hostility, lax or
inconsistent discipline and supervision, and general lack of parental involvement and guidance, all
of which provide a foundation for development of aggressive, antisocial behaviour vulnerable to
substance abuse (EMCDDA, 2010). (Boyd, 1999; Boyd,; Flor, Hollett-Wright, McCoy &
Donovan, 1999; Jacob & Johnson, 1999). According to Merikangas, Dierker & Fenton (1998), in
their studies involving twins, adopted children and children of alcoholic participants found that
genetic factors passed onto the children by parents who, themselves, are substance abusers are
associated with substance abuse in the offspring. Other factors associated with substance abuse
include environmental factors. This has been confirmed in other studies where level of
urbanization, residential patterns, laxity in law enforcement, and collusion with law enforcers, peer
influence, and nature of neighbourhood to which one is exposed, are all probable predictors of
substance abuse (EMCDDA, 2010; Harpham & Blue, 1995; Cardia, 2005; MOH, 2005; Obot &
Anthony, 2000; Rodhes & Jason, 1988).
A south African study conducted among mine workers, 27.8% said that cannabis could give
strength that could help them cope with the heavy workload while 5.4 % said that it could help
them plan and work better. About 1.5% of the respondents said that cannabis helped to make the
work easier. A significant proportion (14%) of the respondents in this study also revealed that
cannabis could help relieve stress whereas 13.9% said cannabis was used for fun (pick et al, 2003).
8
Other predictors of substance abuse have been highlighted as frustration due to unemployment,
academic failure, sexual failure, sexual victimization, physical abuse, poverty, lack of money for
educational opportunities, homelessness, hopelessness, lack of food, lack of proper medical care,
adolescence-experimentation, keeping contact with drug addicts, and absence of parents at home
due to working, incarceration, separation or divorce (Behrman & Wolfe, 2006; Bry, Cataglano,
EMCDDA, 2010; Kumpfer, Lochman & Szapoczinik, 1998; Kumpfer et al, 1998; WHO, 2005;
WHO,2010).
Khat chewing is both a social and cultural activity. It is said to enhance social interaction, playing
a role in ceremonies and important business transactions. It is used to improve performance, stay
alert and increase work capacity. Workers on night shifts use it to stay alert. Yemen khat chewers
believe that it is beneficial for mild ailments like headache, fevers and depression (Glenice and
Rampes, 2003)
Owing to the economic rewards of producing and transporting drugs, drug use has continued to
spread throughout the world (MOH 2005; WHO 2002; WHO 2005). It has been estimated that the
illegal drug market is worth between US$100-500 billion (Reuter, 1996).Global trends in drug
production, transportation and consumption are difficult to describe and evaluate because of the
complexities of that issues involved and lack of accurate information on these covert activities.
A critical synthesis of the foregoing literature indicates that although the factors associated with
substance abuse are many, they can be categorised as genetic, psychological, socio-economic, and
environmental causes. This is actually supported by the work of the International Council of
9
Nurses (2005). However, the studies from which these causes have been compiled were conducted
outside Uganda and in contexts very different from the context of this study. While many of the
cited studies focused on the prevalence of substance abuse, others concentrated on adolescents
rather than adults and yet others focused on parental care in the prevention of substance abuse.
This study was conducted establish the factors associated with drug use in Makindye division,
Kampala district.
2.4 Perceived health effects of substance use
Community surveys and hospital based studies indicate an increase in drug related health
problems, an indication of increase in the drug abuse (NIDA, 2010; Police Report 2010; Police
Report, 2000). The world health report (2002) indicates that 8% of the total burden of disease is a
result of the use of psychoactive substances. Much of the burden attributable to substance use and
dependence is the result of a wide variety of health and social problems including HIV /AIDS
(WHO, 2006).
2.4.1 Perceived health effects of cannabis
The use of cannabis has been associated with the following adverse health effects: Selective
impairment of cognitive function affecting attention and memory processes, exacerbation of
schizophrenia, acute and chronic bronchitis in heavy users and cannabis dependency syndrome.
Prolonged use may lead to permanent impairment. Many studies have shown an association
between cannabis users and increased rates of anxiety ,depression and schizophrenia. Chronic
cannabis has also been associated with motor accidents (NIDA, 2010).The health consequences of
cannabis use in the developing countries are largely unknown because of non -systematic research
(WHO, 2010). This study was designed to establish the perceived health effects of cannabis in
Makindye division, Kampala district.
10
2.4.2 Perceived health effects of khat
There is increasing evidence of harmful health effects and social problems associated with the use
of khat. The drug is a stimulant and produces sleeplessness, gastritis and constipation and a
depressive mood. Other health effects include: tooth decay, irregular heartbeat, decreased blood
flow, myocardial infarction and may worsen pre-existing mental disorders. It also causes increased
libido, infertility, decreased lactation. Prolonged use of khat can lead to impotence and causes low
birth weight in mothers who chew khat during pregnancy (Dalu, A.2008; NIDA, 2007; Ihunwo et
al 2004; Gham et al, 2002).
Although the drug is addictive, in Uganda there are no stringent laws to restrict the use of khat
which has led to marked in increase its use (Waiswa, 2001). The objective of this study was to
identify the health effects of khat use in Makindye division, Kampala district.
11
CHAPTER
3:
STATEMENT
OF
THE
PROBLEM,
JUSTIFICATION
AND
CONCEPTUAL FRAMEWORK
3.1 STATEMENT OF THE PROBLEM
According to the Ministry of Health (2005), 5 to 10% of Ugandans are regular drug users. Reports
from Uganda Police (2010) indicate that abusers of cannabis and khat are increasing in the country,
especially in the suburbs of Kampala district including Makindye Division. Generally substance abuse
has been more prevalent among Ugandan youths with those abusing cannabis and khat in particular
being 7 to 38%.The prevalence of substance abuse in Makindye Division is however not known.
Use of cannabis/ khat is a big health care and economic cost to the country and poses a growing public
health problem to the country. Escalation of use of cannabis/khat leads to reduced productivity of users
and they are vulnerable to health problems as well as the increased likelihood to commit crimes.
As a result, they become a danger to the society and a burden to the health care system.
Increase in the use of khat /cannabis has been attributed to un/underemployment, family
disruption, high rates of school drop-outs availability and affordability (UYDEL, 2009). According
to the Population Census (2002) Cannabis/khat are also used for purposes of functionality to
reduce fatigue, stress cope with harsh environments in which the users live. for instance more than
50% of residents of Makindye stay in slums, engage in informal business, they also have low
literacy levels (Population census, 2002).
Some drugs like khat ( Catha edulis) have no known legislation to control their use. However the
mental health program of the Ministry of Health which collaborates with the Health Promotion and
12
Education division of the School Health program, AIDS control program and health institutions
and NGOs like Uganda Youth Development Link, undertake activities to control drug abuse
(MOH 2005).The primary and secondary curricular also teach about drug use.
The existing body of literature is highly deficient as far as the associated factors and prevalence of
cannabis and khat use in Makindye division, Kampala district are concerned.
This study therefore was conducted to establish the extent of use of cannabis and khat, the health
consequences of abuse and factors associated with use of cannabis and khat in order to address the
existing information gap and contribute to existing interventions by the DHT and other
stakeholders, to control abuse of cannabis and khat.
3.2 JUSTIFICATION
Although substance abuse is extensively covered in the existing body of knowledge (UNODC, 2008;
WHO, 2006; Rehm & Eschmann, 2002; Harpham & Blue, 1995; Obot & Anthony, 2002; George &
Milligan, 2005; Rodhes & Jason, 1988; UNODC, 2004), studies about the prevalence, factors
associated with abuse of cannabis or khat in Makindye division, Kampala district have not attracted
much attention. Even the studies conducted about substance abuse in Uganda have concentrated mainly
on alcohol abuse and in areas outside Kampala District (WHO, 2005), which, surprisingly, is the
reported hub for substance abuse (Uganda Police, 2010). As a result, the factors associated with abuse
of cannabis and khat, the prevalence and adverse health effects are not clear in Makindye division,
Kampala district. Moreover in spite of the improvements in the district’s health service delivery (KCC,
2009), substance abuse is increasing (Uganda Police, 2010).
Abuse of cannabis and khat has been labelled a high cost social problem associated with
unproductive and delinquent behaviour (NIDA, 2010). This will make it difficult to achieve the
13
first MDG of poverty alleviation in Uganda if cannabis and khat is not controlled. Therefore, this
study is necessary to provide information that will help stake holders to know the magnitude of the
problem and strengthen any existing interventions to control the morbidity and mortality associated
with substance abuse. It will also be used as a basis for future studies on cannabis and khat abuse by
scholars.
14
3.3 CONCEPTUAL FRAMEWORK
Conceptual framework for factors associated with substance abuse in Makindye division,
Kampala district
Economic
factors:
-Income
-unemployment
-poverty
Social factors:
-Living environment
-peer influence
-family influence
USE OF
KHAT /CANNABIS
Demographic
factors:
-age
-gender
-education
-religion
-area of origin
Health effects:
-Mental illness
-physical illness
Fig.1
The conceptual framework above shows relationships between the different factors
associated with use of khat / cannabis. They are categorized into economic, social and
demographic factors as well as health outcomes.
Economic factors like unemployment can lead to a poor living environment where it is easy
to access these drugs. On the other hand living in a family where parents or other family
members use cannabis and/ or khat can influence the children (WHO, 2010). Chronic use
15
of these drugs can lead to cognitive impairment which may limit the affected individual
from engaging in gainful employment (WHO, 2010).
Demographic factors affect social factors and vice versa. For instance a person’s education
level affects the peers he interacts with. If they use khat / cannabis, he is more likely to
adopt the practice than someone whose peers do not engage in such practice. Studies show
that gender and age are closely linked to lifestyle and the use of khat / cannabis (Ihunwo et
al 2004;WHO,2010)
Men have been found to engage in the use of khat more often than women (Ageely, 2009).
Adverse health effects have been associated with chronic use of khat / cannabis. Therefore
men are more likely to suffer from adverse health effects of khat and cannabis than women.
Low income and unemployment can affect the heath care seeking behavior of those with
illnesses associated with use of khat/ cannabis. Likewise it is difficult for an individual
with cognitive impairment resulting from use of cannabis or khat to be gainfully employed.
.
16
3.4 Research Questions
1. What is the prevalence of khat or cannabis use in Makindye Division, Kampala District?
2. What factors are associated with khat or cannabis use in Makindye Division, Kampala
District?
3. What are the perceived health effects of abuse of cannabis or khat in Makindye Division,
Kampala District?
17
CHAPTER 4: STUDY OBJECTIVES
4.1 General Objective
The main objective of the study was to establish the prevalence, factors associated with and
perceived health effects of abuse of khat or cannabis in order to provide information to policy
makers, program managers and the District Heath Team to control the abuse of khat /cannabis in
Makindye Division, Kampala District.
4.2 Specific Objectives
1) To determine prevalence of khat/ cannabis use in Makindye division, Kampala district.
2) To establish the factors associated with khat / cannabis use in Makindye division, Kampala
district.
3) To determine the perceived health effects of abuse of cannabis /khat in Makindye division,
Kampala district.
18
CHAPTER 5: METHODOLOGY
5.1 Study area
The study was conducted in Makindye Division, one of the five divisions of Kampala District. It
is located in the South -Eastern part of Kampala District. It is bordered by Central and Lubaga
Divisions in the North-West, Mpigi District in the west, Lake Victoria and Mukono in the South.
Nakawa Division is found in the North- East of Makindye Division. It has got 21divisions and
24% of the population of Kampala city live in Makindye. Seventy per cent of its residents are low
income earners.
5.2 Study population
The study population for this research was people aged 18 years and above.
5.3 Study Design
The study was a cross-sectional study using both qualitative and quantitative methods of data
collection.
5.4 Sample Size determination
The sample was estimated to be 262 respondents using Kish Leslie (1965) formula for cross sectional studies with discrete outcomes as follows:
n = Z2 p q *DE
d2
Where;
d- is the precision.(acceptable degree of error)
z- is the standard normal value corresponding to the 95% confidence level ; z = 1.96.
p- is the proportion of the population who use khat or cannabis.
q = 1-p- those who do not use cannabis or khat.
19
DE =Design effect. This was not was adjusted for which led to a smaller sample size and a bigger
error in estimating the various parameters..
A report of Butabika hospital (2008) showed a prevalence of khat or cannabis use of 19%. The
national estimate of prevalence for cannabis use is 1.4% while that of khat ranges from 0.3-64%
(UNODC, 2007). I used 19% as the proportion with the desired characteristic based on the
Butabika Hospital data for this study. Accordingly, (1-p) which is the proportion of the study
population with the undesired attribute, is given as 1 – 19% = 81%. Therefore:
n = (1.96)2 × 19% × 81% = 3.8416 × 0.25
(5%)2
0.0025
= 0.921984
0.0025
= 236
To adjust for non-response of 10% we divided the estimated sample size by 0.9.
236/0.9 = 262
Therefore, the sample size was 262 respondents.
5.5 Eligibility criteria
5.5.1 Inclusion criteria
All persons aged 18 years and above who were found to have lived in the Makindye division for at
least 30 days prior to the study.
5.5.2 Exclusion criteria
Institutionalised adults like the police and schools teachers were not included. The homeless and
persons who were sick or could not communicate due to disability were excluded.
20
5.6Sampling procedure
5.6.1 Selection of respondents
Makindye Division was selected purposively because it has got the highest population (24%) with
70% of its population comprising of low income earners. Poverty has been sighted by various
scholars as one of the factors associated with use of cannabis/khat.
Multistage sampling procedure comprising of random, and cluster sampling was used. The total
sample of 262 respondents was distributed among the 7out of 21 parishes which were randomly
selected; 4(50%) zones (villages) were then randomly selected from each Parish. The first
household was selected randomly from each zone. Thereafter every 12th adult aged 18 years and
above was randomly selected until the desired number of respondents was obtained from each
zone. Forty percent (120/300) of residents per zone/village were eligible to participate.
5.7.2 Selection of Key Informants: Purposively selected key informants from local leaders, health
officials and police officers from the Narcotic Division of Police were interviewed using a key
informant guide based on the objectives of the study; is attached as appendix 3.
5.7.3 Focus group discussions participants: Participants were selected according to age and
gender to allow free expression as much as possible. Six FGDs were conducted. An interview
guide was used to guide the discussion. A note taker recorded the points raised during the
discussions and the meetings were moderated by the principle investigator. The interview guide is
attached as appendix 4.
5.7 Study Variables
5.7.1 Dependent variable
The dependent variable was whether one used cannabis / khat use(yes/no).
5.7.2 Independent variables

Economic status; income of the household head, employment,

Social factors including peer influence, family influence, environment

Demographic characteristics age, sex, education, religion, region of origin of participants.
21
5.8Quality control

The tools were translated into Luganda, the commonly spoken language in the area.

The data collection tool were pre-tested in Kawempe division, outside the study area .The
findings were used to revise the questionnaire removing the redundant questions..

Research assistants were trained about the objectives of the study and the tools

Data collection tools were checked for completeness and accuracy and the stored safely
after each field day.
5.9 Data Collection: The principal investigator and research assistants interviewed the
respondents, filled the questionnaires and ensured accuracy of information.
Quantitative data was collected using a translated interviewer administered semi-structured
questionnaires.

Qualitative data was collected from key informant using an interview guide.

Key informants interviews were conducted by the principal investigator.
5.10 Data Management and analysis
After collection of the data, the principal investigator checked the completed questionnaires,
checked the data, for consistency and completeness. Data were coded, cleaned and entered using
epidata soft ware. Thereafter data were exported to STATA for analysis.
5.10.1 Uni-variate analysis: All the variables listed in the conceptual framework were used. The
population distribution was described in form of frequencies, pie charts, bar chart and percentages.
The mean and median were used as measure of central tendency, while the inter quartile range
(IQR) was used as a measure of dispersion of the data. Prevalence of substance use was
determined as a proportion of the population participating in the study.
22
5.10.2 Bi–variate analysis: Bivariate analysis was used to explain the relationship between each
of the independent variables and the outcome variable (use of cannabis/khat). It was also used to
determine the strength and significance of this relationship.
Statistical significance and hence generalisability to the population, of the association between
whether one is a user of cannabis / khat or not and the independent variables was tested. F or
variables with at least one categorical variable, the Chi- square statistic was used to test for
significance of the relationship. Chi-square and t-test were used for continuous variables. The
relationship was significant at less than the 0.05 level. The crude Odds ratio (OR) was used to
measure the strength of association between the independent variable and the outcome variable
(use of cannabis/khat). One level of the independent variable was assigned as the reference
variable. Values of the Odds Ratio close to 1 were interpreted as having no relationship to the
outcome variable. OR values less than 1 were interpreted as having a protective effect of the
independent variable from use of cannabis/khat. OR values greater than 1 were believed to have a
causal relationship between the independent variable and the outcome variable. The 95%
confidence intervals were used as a measure of reliability of the estimate of the population
parameter. The p-value was used to measure statistical significance and strength of the the
association between the independent variable and the outcome variable.
5.10.3Multivariable analysis:
This involved simultaneous analysis of many independent
variables in order to draw statistical inference between the independent variable and the outcome
variable. The strength of association was determined using the Adjusted Odds ratio and 95%
confidence interval. Independent variables with a p-value equal to or less than 0.05 were selected
for multivariate analysis. Multiple regression was used to build and assess the suitability of the
model of predictor variables of use of cannabis/khat. The model was assessed for interaction by
23
first forming product terms of the significant variables. The likelihood ratio test to assess whether
there is interaction was done.
Confounding was assessed and adjusting for by running a stepwise test. Confounding was
considered present when the difference between the adjusted and the crude odds ratios was found
to be greater than 10%.
5.10.4 Qualitative data
Qualitative data were checked for completeness, transcribed, analysed manually using the content
analysis technique and presented in form of text. Qualitative data were summarised into themes
which were used to further explain and support the findings from the quantitative data.
5.11 Ethical Considerations

The principal investigator sought approval of the proposal to conduct the study by the
MUSPH IRB and UNCST.

Informed consent of the participants was sought by explaining the purpose of the study and
addressing any concerns like benefits, harmful effects and they were require to sign a
consent form thereafter

To ensure that the data was disclosed unreservedly, confidentiality of respondents was
assured as much as possible by avoiding identifiers like names, locations, and other forms
of identification.

The main risk of the study was stigma. This was mitigated by using “areas of origin” rather
than tribe as well as confidentiality.

The benefits of the study were that the information obtained would bridge the gap in
knowledge and therefore contribute to reduction of abuse cannabis and khat.
24
Dissemination of results
The study findings will be presented to Makerere University School of Public Health and
Makerere University School of Post Graduate Studies, as partial fulfilment for the award of the
degree of Mater of Public Health of Makerere University. The report will also be disseminated to
Kampala city council and copies of the report will be provided to the DHO, the chairman
Makindye division the police and other interested stakeholders. The findings may also be
published in the Ministry of Health bulletin.
25
CHAPTER 6: RESULTS
A total of 263 respondents 6 key informants were interviewed and 3 focus group discussions were
held. All the required respondents were obtained. The results are presented in the following
sections.
6.1 Socio-demographic characteristics of the study participants
Univariate analysis was done to determine the proportions of the characteristics of the independent
variables.
Characteristics of the participants are shown in table 6.1
Table 6.1 Socio-demographic characteristic of respondents
Characteristic
Frequency
N=263
Percent
%
Sex
Male
Female
199
64
75.7
24.3
Age (years)
18-24
24-34
35 +
103
101
59
39.2
38.4
22.4
Religion
Roman Catholic
Protestant
Muslim
Born Again
Other
88
75
66
24
10
33.5
28.5
25.1
9.3
3.8
Area of Origin
Central Uganda
Western Uganda
Eastern Uganda
Northern Uganda
Other
93
61
57
38
14
35.4
23.2
21.7
14.5
5.4
Highest education level attained
Primary
O’ Level
A’ Level
116
100
47
44.1
38.0
17.9
Two of the study participants were non- Ugandans. One was from Kenya and the other form
Tanzania.
26
The majority of the respondents were males constituting 75.7% (199/263). About 39% of the
respondents were aged 18-24 years with a mean 28.8 ± 9 years, median was 27 years. Majority of
the respondents were from Central Uganda (93/263) 35.4% and the least 14.5 % (38/263) from
Northern Uganda. Majority of the respondents were Catholics 33.5% (88/263) and Born Again
Christians were the least 9.3% (24/263). About 44% (116/263) respondents were educated up to
primary seven.
6.2 Prevalence of use of cannabis /khat
Figure6.1 shows use of khat/cannabis in Makindye Division.
Prevalence of Cannabis/khat use in
Makindye Division
50
42
Percent
40
34.6
30
20
15.6
7.8
10
0
Cannabis
khat
both
none
Khat/Cannabis use
All the Key Informants and Focus Groups agreed that cannabis and khat were commonly used
substances and one of the key informants elaborated:
“The problem of using cannabis and khat is increasing; 4 out of 10 youths use cannabis especially,
in abattoirs, prostitutes and the unemployed (KI, KCCA). In another interview the KI said: “.....
Others smoke Cannabis and some chew mairungi/khat. Young people from seventeen years smoke
cannabis very much in this Division. I don’t know whether it is about poverty. What is surprising is
27
that even Makerere University students smoke cannabis. When I was growing up, I never saw any
woman smoking cannabis; but these days even women smoke cannabis (Katwe Police Station).
6.2.2 Frequency of use of cannabis / khat by participants
Table 6.2 shows frequency of substance use among participants who were in current use of
cannabis / khat at the time of the study. Among participants in current use of cannabis / khat,
87.7% (135/154) used cannabis/ khat daily. The data is presented in table 6.2.
Table 6. 2. Frequency of use of cannabis / khat.
Consumption of khat/cannabis
Frequency
Per cent
Daily
135
87.7
Once/week
6
3.9
Once in two week
2
1.3
Once /month
11
7.1
All the key informants and FGD agreed that cannabis and khat were consumed daily. ‘There is no
specific day and time for use of the substance. Cannabis is smoked any time while hiding before
work. Khat is taken any time of the day. People use cannabis everyday when they are arrested and
taken to prison, when they pay bail and come out they continue with the habit. Khat chewing: that
one is very common moreover there are even no laws prohibiting its use ” ( KI, Katwe Parish).
28
6.3 Factors associated with use of cannabis /khat
6.3.1 Availability of cannabis / khat.
About 14.8% of the study participants bought cannabis/khat from vendors, while 63% were
vendors of cannabis/khat. About 22 % did not disclose the source where they obtained these
substances from. With regard to the availability of cannabis/khat, the 6 Key Informants and all
FDG members agreed that cannabis and khat were readily available. The consensus was that
though illegal, cannabis was readily available in Makindye division.
One KI said: “You as a person from outside who is not well known here you can’t get cannabis
because the sellers are not very comfortable with you and may think that you are a spy for the
police but for those they know it is easy to get cannabis. These people who sell cannabis do not
mind even when you arrest them. When they pay bail and they come out of prison they go back to
their business as if nothing has happened. When you ask them why they sell cannabis they say it
the source of their children’ school fees” (KI ,Katwe Parish).
6.3.2 Participants reasons for use of khat /cannabis
Table 6.3 shows the study participants’ reasons for taking drugs.
Table 6.3: Study participants’ reasons for use cannabis / khat.
Reasons for cannabis and khat use
Frequency
Percent (%)
N= 256
It helps me forget my problems
68
26.6
It helps me to get appetite
81
31.6
It helps me to get courage
58
22.7
It helps me to sleep well
49
19.1
29
6.4. 3 Problems associated with use of cannabis/ khat
On further inquiry about the problems which made respondents use drugs, the following responses in
table 4 were reported. About 22% attributed drug use to poverty, unemployment and debts, 18.5% loss
of parents, 11.1% domestic violence. Other problems mentioned by participants were: peer pressure,
staying awake, calm down, increase libido and prevent sickness. These problems were also emphasised
by one key informant: “people especially the youth use cannabis and khat because of frustration, and
unemployment”(Principle Health Inspector, KCC). Another KI said “They use cannabis to get more
energy. It is greatly believed that the use of cannabis and other substances increase strengths to do
labour intensive tasks” (KI chairman LC1 Kabalagala). “They use mairungi to stay awake, alert and
concentrate; especially long distance drivers”(Counsellor, Haven Alcohol and Drug Addiction
Rehabilitation Centre)
Table 6.4: Problems that make respondents use drugs
Problems causing participants to use cannabis or khat
Frequency
Percent
N=20
Unemployment /poverty/debts
6
22.2
Loss of a parent
5
18.5
Domestic violence
3
11.1
Others (peer pressure/stay awake/calm down/ increase libido/prevent sickness)
6
22.2
NB: multiple response question.
6.3.4 Affordability of cannabis / khat
Cannabis and khat are affordable substances. For instance the minimum cost for a stick, the
smallest measure of cannabis on the market, is 500 Uganda shillings (US$ 0.2) and 1000 Uganda
shillings (US$ 0.4) for a bundle of khat. In all the FGDs and KIs interviews conducted, the
30
participants agreed that the cost of cannabis ranged from Uganda shillings. 200 -500 per stick;
while the cost of a bundle of khat was Uganda shillings 1000-1500, which is affordable. One of the
key informants observed that many substances were locally grown in the nearby districts and were
affordable as elaborated in the following statements:. “Substances like cannabis and khat are
cheap. (KI, LC1 Chairman Wabigalo). A stick of cannabis of 500shillings can be shared by 10
users by puffing once each (KI, Haven for Alcohol and Drug Addiction Rehabilitation).
6.3.5 Age at initiation of use cannabis/khat
Results in the table show that the majority of users started drug use below 18 years.
Table 6.5 Age at initiation of cannabis /khat use
Age
Frequency
Percent
<18
78
50.6
>18
76
49.4
6.4 Perceived health effects of use of khat / cannabis
The majority of participants 61.6% (162/263) said they were aware that using cannabis/khat could
lead to health effects; 37.6% (99/263) were not aware and 0.8 % (2/263) said that cannabis was
used to treat malaria and AIDS. Table 6.6 shows the health effects mostly reported by the
respondents.
One KI said “HIV /AIDS has also promoted the use of cannabis because it relieves pain and
hopelessness. Some youths associate the use of cannabis and khat with energy, bravery since some
musicians who use the are successful” (Health Inspector, KCC; all FGDs).
31
Table 6.6 Perceived health effects of use of khat / cannabis.
Adverse effects of cannabis/khat abuse
Frequency
Percent (%)
N = 167
Mental illness
59
35.3
Lung cancer
46
27.5
Gastrointestinal problems
20
12.0
Aggressive behaviour
9
5.4
Headache
9
5.4
Memory loss
7
4.2
Lowers immunity
3
1.8
Respiratory diseases
2
1.2
Others
12
7.2
6.5.1 Relationship between socio-demographic factors and the use of khat /cannabis
Bivariate analysis was done to establish statistical significance and strength of association between
independent variables and the dependents variable (use of khat/cannabis).
Table 6.7 shows results of the relation between demographic characteristics and the use of khat
/cannabis. Majority of users, 46.1% (71/154) were 25-34years. Respondents 25-34 years were 3.5
times more likely to use khat/cannabis than those aged 35 years and above and the association
between age and use of khat/cannabis was statistically significant (p-values = 0.001, 0.000
respectively). Compared to those with higher education, respondents without formal education
(OR= 6.1, 95% CI; 2.087-18.279), were 6.1, more likely to use cannabis/khat. The association
between level of education and use of khat/cannabis was statistically significant (p=values 0.001).
The respondents from Northern Uganda were 3 times more likely to use cannabis/khat than those
from Eastern Uganda and the association between Northern Uganda and use of khat/cannabis was
statistically significant (p-value =0.012). Details are displayed in the table below.
32
Table: 6.7 Relationship between socio-demographic factors and the use of khat /cannabis
Variable
Users
N=154 %
Non Users
N=109 %
OR
95% CI
p-value
Gender
Male
Female
119
35
77.3
22.7
80
29
73.4
26.6
1.2
1.0
0.70 -2.18
Reference
0.470
Age
18-24
25-34
35 +
59
71
24
38.3
46.1
15.6
44
30
35
40.4
27.5
32.1
2.0
3. 5
1.0
1.02 -3.75
1.76 -6.76
Reference
0.001*
0.000*
Highest
Education level
attained
No education
Primary
O’Level
A level
21
58
57
17
13.6
38.0
37.0
11.0
6
30
43
30
5.5
27.5
39.4
27.5
6.1
3.5
2.3
1.0
2.09- 8.28
1.66- 7.27
1.15- 4.78
Reference
0.001*
0.001*
0.020*
Religion
Roman Catholic
Protestant
Muslim
Other
51
45
43
7
33.1
29.2
27.9
4.5
37
30
23
3
33.9
27.5
21.1
2.8
3.7
3.0
4.7
2.8
1.39- 10.07
1.14 - 7.88
0.95- 3.04
1.07 - 7.12
0.009*
0.026*
0.059
0.036*(fet)
Born Again
8
5.2
16
14.7
1.0
Reference
Area of origin
Central Uganda
Western Uganda
Southern Uganda
Northern Uganda
Eastern Uganda
55
36
8
28
27
35.7
23.4
05.2
18.2
17.5
38.
25
4
10
30
34.9
22.9
03.7
09.2
27.5
1.6
1.6
2.2
3.1
1.0
0.83- 3.13
0.77 - 3.32
0.60- 8.22
1.28 -7.57
Reference
0.161
0.206
0.231
0.012*
*Statistically significant association between the independent variable drug use. Fisher’s exact
test (fet).
33
6.5.2 Relationship between other factors and the use of khat/ cannabis
Table 6.6 .2 shows results of relationship between other factors and the use of khat/cannabis
Compared to residents of Nsambya Barracks, participants from Katwe II (OR= 7.4, 95%CI; 2.2324.58) were 7.4 times more likely to use cannabis/ khat and association between living
environment and use of khat/cannabis was statistically significant. Participants whose friends were
users of cannabis/ khat were 5 times more likely to use these substances than those who did not use
cannabis/ khat (OR=5; 95% CI; 1.43-18.44) and the association between one’s friend who used
cannabis/khat, and use of these substances was statistically significant (p= 0.003). As expected,.
Respondents whose family members used cannabis/khat were 2.1 times more likely to use
cannabis/khat (OR= 2.1, 95% CI; 1.204- 3.788) and this relationship was statistically significant
(p= 0.009). The results further show that those who knew the harmful effects of these
cannabis/khat were 0.3 times less likely to use cannabis/khat (OR= 0.3, 95% CI; 0.16-0.45) and
association between knowledge of health consequences of abuse and use khat/cannabis was
statistically significant (p= 0.000).
34
Table 6.6.2 Relationship between other factors and the use of khat /cannabis
Variable
Users
Non Users
Odds
Ratio
95% CI
P -value
N=154
%
N=109
%
Income (‘000)
Less than100
100-200
200+)
62
72
20
56.4
63.2
51.3
48
42
19
43.6
36.8
48.7
1.2
1.6
1.0
0.59- 2.55
0.78-3.39
Reference
0.356
0.193
Area of residence
Bukasa
Buziga
Katwe II
Kisugu
Salaama
Wabigalo
15
14
21
36
33
13
75.0
56.0
84.0
53.7
57.9
81.3
5
11
4
31
24
3
25.0
44.0
16.0
46.3
42.1
18.7
4.2
1.8
7.4
1.6
1.9
6.1
1.34-13.35
0.69- 4.69
2.23-24.58
0.79- 3.39
0.91- 4.14
1.55 - 24.01
0.014*
0.233
0.001*
0.185
0.087
0.010*
Nsambya Barracks
Use by friend
22
41.5
31
58.5
1
Reference
Yes
No
82
72
53.2
46.8
42
67
39.5
61.5
5.1
1
1.43- 18.44
Reference
0.003*
Use by family member
Yes
No
100
54
71.1
53.5
87
22
46.5
28.9
2.1
1
1.20-3.79
Reference
0.009*
Yes
75
46.3
87
53.7
0.3
0.16-0.45
0.000*
No
79
78.2
22
21.8
1
Reference
Knowledge of health
consequences of cannabis
or khat
*statistically significant association between the independent variable and drug use. Fisher’s
exact test (fet), reference variable (ref)
35
6.6 Multivariate analysis of factors associated with use of khat /cannabis.
Multvariate analysis was done to determine the predictors of use of khat/cannabis. The most
significant predictors of use of khat/cannabis were age, education, religion, use of cannabis/khat by
family member and persons with mental illness as shown in table 6.8 .
Table 6.8: Unadjusted Odds ratio and adjusted odds ratio (OR) and 95% confidence intervals
(95%CI) of factors associated with use of khat /cannabis
Variable
Crude OR
95% CI
Adjusted OR
95% CI
Age group
18-24
25-34
35+
2.0
3.4
1
1.02-3.75
1.76- 6.76
-
3.1
2.1
1
1.37-7.10
1.16- 3.86
Reference
Education level
No formal education
Primary
O’ Level
Advanced Level
6.2
3.5
2.3
1
2.09 – 18.28
1.66 -7.27
1.15-4.78
-
3.3
1.9
2.0
1
1.15 – 9.63
1.04 – 3.53
*0.88-4.66
Reference
Religion
Roman Catholic
Protestant
Muslim
Born Again
2.8
3.0
3.8
1
1.07 – 7.12
1.14 – 7.88
1.39 – 10.05
-
3.7
3.1
3.8
1
1.30-10.74
1.10- 9.17
1.28- 1.44
Reference
Use by friend
Yes
No
5.1
1
1.43-18.44
-
3.8
1
*0.83-18.11
Reference
Use by family member
Yes
No
2.1
1
1.20-3.90
-
2.1
1
1.10-3.92
Reference
0.3
1
0.15-0.54
Reference
Has Mental Illness
Yes
0.3
0.17-0.48
No
1
*Factor was not significant at multivariable regression
36
CHAPTER 7: DISCUSSION
7.1 Prevalence of use of cannabis and khat in Makindye
This study found that prevalence of cannabis use (15.6%), khat (34.6%) and use of both cannabis
and khat was 7.8% in Makindye division, Kampala Uganda. This prevalence was lower than that
of a study conducted in Buvuma Islands, Uganda; (24%) cannabis and (43%) khat (Bitakalamire,
2006). Studies in Ethiopia, Kenya and Yemen among the general population also showed that
cannabis was the most commonly used illicit drug (Dalu, 2008). Khat is also commonly consumed
although in Kenya, Ethiopia and Uganda there are no regulatory laws (UNDOCCP, 1999).
Findings by this study on the consumption of khat were similar to those by Glenice and Rampes
(2003) in which it was reported that khat is widely consumed in Uganda, Kenya, Somalia, Ethiopia
and Madagascar, where the legality of its consumption was not clearly understood.
7.2 Factors associated with use of cannabis / khat among residents in Makindye division.
A number of factors were found to be associated with use of cannabis and khat. The main ones are
highlighted in the following sections
7.2.1 Age and use of cannabis/khat
This study found that the mean age of the respondents was 28.8 years. These results show that
residents of Makindye division were generally a young population. There was a significant
association between age and use of cannabis/khat. In this study, younger respondents were more
likely to use cannabis/khat. The finding are similar to those in a study by (Nkowane& Jansen,
2000) where it was found that the use of cannabis starts in adolescence.
37
7.2.2 Education level of participants and use of cannabis/khat
The education level of most respondents in this study was up to primary seven. The findings
indicate that residents of Makindye division were mainly of low education background. There was
a statistically significant association between education and use of cannabis and khat. The reasons
for this characteristic could be attributed to urban migration and poverty, where people engage in
stressful less skilled work and live in poor conditions (Africa annual report on drug abuse, 2004).
7.2.3 Religion and use of cannabis/khat
The respondents were from all the major religious denominations; with the majority being
Catholics. Muslims were most likely to use cannabis and khat (OR= 3.8, 95%CI; 1.28-1.44) The
associations between religion and drug use was significant. This did not conform with other studies
(Waiswa, 2001 ) which found that religion was protective against drug use. For instance in Saud
Arabia, the use of khat is discouraged because it has no foundation in Islam (Dalu, 2008). The
weakness of this study in this regard was that we did not have a measure for strength of belief.
7.2.4 Family influence and use of khat/cannabis
Parental guidance and monitoring plays a crucial role in the development of a child. In this study,
respondents who had a family member using khat or cannabis, 71.1% were users compared to 53%
users who did not have anyone in their family using these substances. This association between
family influence and substance use was significant. This finding agrees with what was found in a
study in secondary schools in Kabalore where smoking of cannabis and chewing of khat by parents
and siblings was likely to influence use of these substances by another member of the family
(Waiswa, 2001; Havell, 2004).
38
7.2.5 Use of cannabis/khat by friend and use of khat/cannabis
This study found that 72 % of users of cannabis / khat shared their problems with friends ,most of
whom were their peers. Peer influence is a very important factor associated with risk behaviour
because individuals need a sense of belonging to social networks. This study agrees with findings
from similar studies (Behrman & Wolfe, 2006; Bry, Cataglano, EMCDDA, 2010; Kumpfer et al,
1998; WHO, 2005; WHO,2010). The association between significant other, and in this study
mainly peers, and use of cannabis and khat was statistically significant (p= 0.003).
7.2.6 Frequency of use of cannabis or khat
The study revealed that majority of participants had used cannabis / khat daily for at least one year.
Approximately 87.7% consumed cannabis / khat daily. These findings are distinctly higher than
those reported in a USA study where 12.2 % used cannabis daily (SAMHSA, 2004; Waiswa,
2001). The daily and prolonged use of drugs could be related to the nature of the participants’
economic status and living conditions. From these findings it can be predicted that use of
khat/cannabis is a very big public health problem in this population with dependence levels likely
to be high.
7.3 Perception of health consequences of use of khat or cannabis
In this study we wanted to know whether the participants knew about health consequences of
abuse of cannabis or khat. About 62% (162/263) said they were aware that using cannabis or khat
could lead to health consequences. 78% of respondents who did not know heath consequences
were users compared to 46% of those who knew. Knowledge of health consequences was a
protective factor against use of cannabis or khat. Those who knew health consequences were 0.3
times less likely to use the substances than those who did not know. This association was
39
significant. This finding agrees with earlier studies where it was found that awareness of these
consequences has been associated with decreased risk of use of substances (Baliesima, 2003).
7.4 Study limitations

Recall bias: Respondents were required to remember events that had occurred many years
ago. This was addressed in part by limiting the recall period to one year and 30 days.

Stigma: Under reporting of drug related behaviours for fear of stigma and prosecution
resulting from disclosure. Some substance users found it difficult to provide authentic data
on this behaviour. Attempts were however made to explain to respondents that information
obtained from them would be used for academic purposes and where possible to improve
service provision and that data would be presented in a confidential manner within limits of
the law in order to increase their trust

We did not adjust for design effect which approximates the sample to a random sample.
This led to a small sample size which may limit generalisability to the general population.
.
7.5 Conclusion
The prevalence of cannabis/ khat use is 15.6%/34.6% in Makindye Division. Cannabis/ khat use
was associated with: Use of cannabis/ khat by family member, Use of cannabis/ khat use by friend,
Low education level. About 62% were aware of the main health effects of cannabis/khat.
40
7.6 Recommendations
The prevalence of khat / cannabis use is 15.6/34.6 in Makindye division and has the potential to
increase morbidity and mortality. Findings from this study suggest the need for a multi-sectoral
approach with the objective of preventing and reducing use of cannabis/ khat among the Makindye
Division community while managing the related problems. The following recommendations are
made from this study

Government should enact and enforce restrictive measures since cannabis/ khat were found
to be affordable and easy to get in Makindye Division.

The ministry of health should design mass health education programs and messages
specifically designed to target all sections of the community since friends’ influence was a
significant predictor of use of cannabis /khat.

Government should strengthen education programs since this people with low level of
education were more likely to use cannabis/ khat was.

The Kampala City Council Authority Health Team in collaboration with the police , MOH
and NGOs should embark on massive community sensitisation about the health effects
cannabis and khat abuse since knowledge of the health consequences was found to be a
protective against use of cannabis and khat.

Family role models were found to be a significant predictor of use of cannabis / khat.
Prevention programmes should target the whole family.
41
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Bry, BH., Cataglano, RF., Kumpfer, KL., Lochman, JE., & Szapoczinik, J (1998), ‘Scientific
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on 27/07/2010, http//www. The sidam concern.com/articles/abrham.html.
Duncan, SC., Duncan, T. & Stryker, LA (2000).
‘Risk and protective factors influencing
adolescent problem behaviour: A multivariate latent growth curve analysis’, Annals of
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Einstein, E., Aquino, M.T., Caldeira, Z., Friere, Z., & Baptista, M. (2005). ‘Youth and Drugs in
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45
APPENDIX 1: CONSENT FORM
Good morning /Good Afternoon Sir /Madam.
Thank for accepting to participate in this study. My name is Kasule Hafisa. I am a graduate
student from Makerere University School of Public Health. We are looking for information about
use of khat and cannabis in this area. The information you give us will help us know how this
problem is so that we can find ways of managing this problem. Your selection to participate in this
study is by chance alone and your responses will be treated with confidence. The responses you
give will not reveal your identity to anyone not part of this study. Any publication of such
information will conceal your identity. You are free to withdraw your participation at any time of
the study without any penalty.
We request that you participate in this study. If you agree to participate, please give us your true
opinion / knowledge about the questions that will be asked. If you do not understand what has been
asked, you can ask us to clarify the question. This will take about 25 minutes of your time. Please
do not hesitate to ask if you have any questions concerning this matter.
All information given will be confidential ..
Have understood?
Yes
Do you agree to participate Yes
No
No
Name of respondent…………………………………………………...
Signature of respondent………………………………………………
Signature of interviewer……………………………………………..
Date…………………………
46
APPENDIX 2: RESPONDENT QUESTIONNAIRE FOR THE ABUSE OF KHAT OR
CANNABIS SURVEY IN MAKINDYE DIVISION, KAMPALA DISTRICT.
Questionnaire No:…….
Date:…………………
Parish…………………….
This questionnaire is about the use and abuse of cannabis or khat. It has been designed to
collect data from people aged 18 years and above who live in Makindye Division. The
information you will give us will be used to help in developing programs to control the abuse
of cannabis and khat. The information provided will be confidential and hence you do not need
to tell us your name. We however request you to give correct information to the questions
that follow.
SECTION A
The following questions are about your social economic status and demographic
characteristics
1. Age…………(only respondents 18years and above are eligible)
2. Sex
1.) male
2)female
3. Highest education level attained
i.
ii.
iii.
iv.
v.
never went to school
p1-p7
s1-s4
s5 -s6
tertiary education
4. Religion
i.
ii.
iii.
iv.
v.
Protestant
Pentecostal (born again)
Roman catholic
Muslim
Other
5. Area of origin
1)Central Uganda 2) Western Uganda 3) Eastern Uganda 4) Northern Uganda
47
SECTION B The following questions are about the use of cannabis.
6. Have you ever smoked cannabis or chewed khat?
1)Yes
2) No
7. How old were you when you started using cannabis or khat?……………………..
8. During the last 30 days on how many days did you smoke cannabis?.........
9. In the past 7 days how many times did you use cannabis or khat?
10 During the past 12 months did you try to stop smoking cannabis or chewing
khat?
1) I did not smoke cannabis
2) Yes
3) No
11. How do you get cannabis / khat?.............................................................
12. How much does cannabis / khat cost?.......................................................
13. Have you gone to anyone to get help about a problem with cannabis or khat?
1)Yes
2) No
14. Have you been involved in a treatment program specifically related to cannabis or khat
use?
1)Yes
SECTION C
2) No
Health effects of abuse of cannabis or khat.
a) The following questions are about health effects of abuse of cannabis
or khat.
15. Do you think smoking cannabis or chewing khat is harmful to health?
16. If the answer is yes, what problems can one get from smoking cannabis? (mention 3)
………………………………………………………………………………………………………………………
………………………………………………………………………………………
17. Have you had "blackouts" or "flashbacks" as a result of cannabis or chewing
1) Yes
2) No
48
khat?
18. Are you always able to stop using drugs when you want to?
1) Yes
2) No
19. If yes, have you ever experienced withdrawal symptoms (felt sick) when you stopped
taking cannabis or khat?
1) Yes
2) No
20. Have you had medical problems as a result of your cannabis or chewing khat (e.g.
memory loss, hepatitis, convulsions, bleeding, etc.)?
1)Yes
2) No
b) The following question is about sad feelings. Some people feel sad and fearful about the
future and feel like ending their life.
21. During the past 12 months did you ever feel hopeless almost every day for about two
weeks or more that you stopped some routine activities like eating, bathing, working, etc?
1)Yes
2) No
c) The following questions are about sexual behaviour
22. Have you ever had sexual intercourse?
1)Yes
2) No
23. How old were you when you had sex for the first time?....................................
24.. Did you smoke cannabis or chew khat before you had sexual intercourse the last time
you had sex?
1)Yes
2) No
25. What method do you use to prevent pregnancy?..............................................
SECTION D
Factors associated with abuse of cannabis or khat
26. Why do you use cannabis or khat?
1) it helps me to forget my problems(please give examples)
2) it helps me to get appetite
49
3) it helps me to get courage
4) it helps me to sleep well
5) it helps me to get strength to work for long hours without getting tired
Please answer yes or for questions 32-37
27. Do you ever feel bad or guilty about using cannabis or khat?
28. Have you lost friends because of your use of cannabis or khat?
29. Have you been in trouble at work because of cannabis or khat abuse?
30. Have you lost a job because of cannabis or khat?
31. Have you engaged in illegal activities in order to obtain cannabis or khat?
32.Have you been arrested for possession of illegal cannabis?
The following questions are about use of cannabis or khat b important people in
your life.
33. Does any one in your family use of cannabis or khat?
1) Yes
2)No
34. Who is your significant other?.....................................
35. Does your significant other use cannabis or khat
1)Yes
2)No
Thank you for your valuable time.
END
50
APPENDIX 3: KEY INFORMANT GUIDE
I am student from Makerere University School of Public Health. I am conducting study on abuse
of cannabis and khat in Makindye Division. The information obtained in this study will
recommend appropriate interventions for controlling abuse of cannabis or khat. Outlined below are
questions to guide this discussion.
1. Do you believe that the use of khat or Cannabis is a public health problem in Kampala?
………………………………………………………………………………………………………
…………………………………………………….
2.What do think are the factors associated with the abuse of khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………
3.What are the health consequences associated with abuse khat or Cannabis?
……………………………………………………..........................................................................
4. How do people get khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………………………………
5 Are there any interventions by government to control abuse of khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
6.Do you think this problem is increasing? Please explain…
…………………...............................................................................................................................
Thank you for your valuable time
END
51
APPENDIX 3: FOCUS GROUP DISCUSSION GUIDE
I am student from Makerere University School of Public Health. I am conducting study on
use/abuse of cannabis and khat in Makindye Division. I will moderate the discussion and my
colleague will take notes. The information obtained in this study will recommend appropriate
interventions for controlling abuse of cannabis or khat. Outlined below are questions to guide this
discussion.
1. Do you believe that the use of khat or Cannabis is a public health problem in Kampala?
………………………………………………………………………………………………………
…………………………………………………….
2.What do think are the factors associated with the abuse of khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………
3.What are the health consequences associated with abuse khat or Cannabis?
……………………………………………………..........................................................................
4. How do people get khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………………………………
5 Are there any interventions by government to control abuse of khat or Cannabis?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
6.Do you think this problem is increasing? Please explain…
…………………...............................................................................................................................
Thank you for your valuable time
END
52
Appendix 4: Map of Makindye division
53