Patterns of Psychoactive Substance Misuse in Undergraduate University Students: The Case of Mekelle University, Ethiopia

Round 1

Reviewer 1 Report (New Reviewer)

The paper is quite interesting regarding the topic of misuse among university students, I think that it could be of interest even for an international reader, by the way I think they should add a comparison about the comparison of alcohol use (median alcohol per year among Ethiopian pop, their sample and other countries); a comparison of Ethiopian Law and other countries (I think they should read and cite the following paper: doi: 10.3390/ijerph17228704.). However the paper is well written and the study design is well done.

Author Response

Authors response to Reviewers’ comments.

 

Reviewer 1

Reviewer’s comment # 1: The paper is quite interesting regarding the topic of misuse among university students, I think that it could be of interest even for an international reader, by the way I think they should add a comparison about the comparison of alcohol use (median alcohol per year among Ethiopian pop, their sample and other countries); a comparison of Ethiopian Law and other countries (I think they should read and cite the following paper: doi: 10.3390/ijerph17228704.). However, the paper is well written and the study design is well done.

Authors’ response: Despite there is no consolidated population level data on the consumption of alcohol in terms of median alcohol per year, we have included an indirect estimates of alcohol consumption in terms of age at first use of substances and life time prevalence of substances from Demographic health survey and systematic review.  We have included information about the age at first use for alcohol and Tobacco (line #273-275), we have included

“as the age at first exposure for students is becoming lower across a time (13,48-50). Previous study shows that the mean age of undergraduate University students at their first-time use of alcohol is 16 and while it is 17 for tobacco (13)”.

In addition we included information on the prevalence of alcohol consumption in Ethiopia in line #284-286, 

“Ethiopia is among the countries with high prevalence of alcohol consumption among adult population and nearly half of the population is lifetime user for alcohol” (Zemenu T, 2020, Getinet Ayano).

 

 

Reviewer 2:  

Reviewer’s comment # 1: I think the exploratory qualitative study conducted by the authors is outdated. With the Covid 19 pandemic, drug use trends have changed. A comparison of substance consumption by university students before and after the Covid 19 pandemic would be more interesting. The article must be rejected.

Authors’ response: We acknowledge the reviewer’s concern regarding the need to articulate how the findings from qualitative conducted in 2017 are still viable to generate knowledge in reference to the COVID-19 pandemic. However, we respectfully disagree with the argument the that the findings are outdated to be considered after the COVID-19 pandemic mainly for three reasons.

1^st. The study is a qualitative study with no reports on quantitative measures such as prevalence, as prevalence studies are prone to time and event related variations in reference to the pandemic. Addictive behaviors such as substance misuse is rather prolonged individual and group behavior that often needs supporting interventions to cease. On the other hand, among the changes COVID-19 brought to the global mental health crises is the increased prevalence of psychoactive substance users in the general population (some reported up to 20%). With this information in mind, it is expected that a greater number of students in colleges and Universities around the globe are also at risk of the pandemic and the uncertainty related to it. Hence, understanding and predicting the pattern of the misuse among students is still a viable body of knowledge in addressing global mental crises in the context of COOVID-19.        

2^nd. Understanding the patterns regarding when and where do university students misuse psychoactive substances leverage decision-makers and implementers in designing effective COVID-19 intervention to sensitive to contextual factors for the substance users

3^rd. As Universities are among the settings that are prone for propagation of COVID-19, understanding the patterns of addictive behaviors is crucial as they are closely linked to adherence for the prevention mechanisms.    

 

 

 

Reviewer’s comment # 2: Furthermore, in the manuscript they refer to a Table 1, which is not attached but has to be retrieved from a similar article already published (https://doi.org/10.1186/s13011-018-0190-1).  10.1186/s13011-018-0190-1

 

Authors’ response: As explicitly cited in the current manuscript on page 2 Line 52, the current manuscript is part of the same project with the previously published article found “10.1186/s13011-018-0190-1”. Hence, the table referred in the current manuscript is already published in the previous work. The current manuscript was originally submitted to International Journal of environmental and Public Health (IJEPH) and transferred to Challenges journal along with the authors’ response to the comments from the previous journal. The manuscripts share the same description of study participants. Therefore, the reviewers in the previous journal have commented that if it is published elsewhere, better to cite it than including it again in the current manuscript just to avoid duplication. The conversation with the previous reviewers is provided below. However, if the need to explain it more seems required, we well be hearing from you.

 

Reviewers’ comment:  Table 1 is the same one used by the authors in a previous publication. I suggest checking with the editors of that previous publication whether this does not break any copyrights.

Authors’ response: Thank you for the suggestion, It sounds that publishing the table, which is already published elsewhere may cause unnecessary replication. Hence, we would like to hear more from reviewers and the editor of the current manuscript that if we can refer to/cite the previously published table from the previous publication indicating the exact page where it is found. If this doesn’t seem sound, we may replicate it in consultation with the editors of the previous publication. From our point of view the former option sounds better. We better rephrased it as “The table that summarized the scocio0demographic characteristics of the participants is published elsewhere (13 p.3 )”. Hence, we preferred to avoid submitting it as a table to the current submission.

 

Overall, as authors of the current manuscript, we have made necessary revisions to address the reviewers’ comments and suggestions. We also conducted a thorough revision on the reference section to make the current manuscript informed from the recent outmost and quality evidence. Old references are removed and replaced by newer ones and duplicated we minimized the number of references with similar findings in our citation. We have also verified the studies cited in the manuscript. 

Reviewer 2 Report (New Reviewer)

When and where do undergraduate university students use Psy- choactive substances; the case of Mekelle University, Ethiopia

The authors conducted an exploratory qualitative study from April 1 to May 30, 2017 to explore when and where university students misuse psychoactive substances. The study showed that students consume alcohol in the evenings, on weekend days, holidays, after exams and at celebrations; smoke cigarettes after waking in the morning and after eating lunch.

 

Comments:

I think the exploratory qualitative study conducted by the authors is outdated. With the Covid 19 pandemic, drug use trends have changed. A comparison of substance consumption by university students before and after the Covid 19 pandemic would be more interesting. Furthermore, in the manuscript they refer to a Table 1, which is not attached but has to be retrieved from a similar article already published (https://doi.org/10.1186/s13011-018-0190-1). 

The article must be rejected.

Author Response

Authors response to Reviewers’ comments.

 

Reviewer 1

Reviewer’s comment # 1: The paper is quite interesting regarding the topic of misuse among university students, I think that it could be of interest even for an international reader, by the way I think they should add a comparison about the comparison of alcohol use (median alcohol per year among Ethiopian pop, their sample and other countries); a comparison of Ethiopian Law and other countries (I think they should read and cite the following paper: doi: 10.3390/ijerph17228704.). However, the paper is well written and the study design is well done.

Authors’ response: Despite there is no consolidated population level data on the consumption of alcohol in terms of median alcohol per year, we have included an indirect estimates of alcohol consumption in terms of age at first use of substances and life time prevalence of substances from Demographic health survey and systematic review.  We have included information about the age at first use for alcohol and Tobacco (line #273-275), we have included

“as the age at first exposure for students is becoming lower across a time (13,48-50). Previous study shows that the mean age of undergraduate University students at their first-time use of alcohol is 16 and while it is 17 for tobacco (13)”.

In addition we included information on the prevalence of alcohol consumption in Ethiopia in line #284-286, 

“Ethiopia is among the countries with high prevalence of alcohol consumption among adult population and nearly half of the population is lifetime user for alcohol” (Zemenu T, 2020, Getinet Ayano).

 

 

Reviewer 2:  

Reviewer’s comment # 1: I think the exploratory qualitative study conducted by the authors is outdated. With the Covid 19 pandemic, drug use trends have changed. A comparison of substance consumption by university students before and after the Covid 19 pandemic would be more interesting. The article must be rejected.

Authors’ response: We acknowledge the reviewer’s concern regarding the need to articulate how the findings from qualitative conducted in 2017 are still viable to generate knowledge in reference to the COVID-19 pandemic. However, we respectfully disagree with the argument the that the findings are outdated to be considered after the COVID-19 pandemic mainly for three reasons.

1^st. The study is a qualitative study with no reports on quantitative measures such as prevalence, as prevalence studies are prone to time and event related variations in reference to the pandemic. Addictive behaviors such as substance misuse is rather prolonged individual and group behavior that often needs supporting interventions to cease. On the other hand, among the changes COVID-19 brought to the global mental health crises is the increased prevalence of psychoactive substance users in the general population (some reported up to 20%). With this information in mind, it is expected that a greater number of students in colleges and Universities around the globe are also at risk of the pandemic and the uncertainty related to it. Hence, understanding and predicting the pattern of the misuse among students is still a viable body of knowledge in addressing global mental crises in the context of COOVID-19.        

2^nd. Understanding the patterns regarding when and where do university students misuse psychoactive substances leverage decision-makers and implementers in designing effective COVID-19 intervention to sensitive to contextual factors for the substance users

3^rd. As Universities are among the settings that are prone for propagation of COVID-19, understanding the patterns of addictive behaviors is crucial as they are closely linked to adherence for the prevention mechanisms.    

 

 

 

Reviewer’s comment # 2: Furthermore, in the manuscript they refer to a Table 1, which is not attached but has to be retrieved from a similar article already published (https://doi.org/10.1186/s13011-018-0190-1).  10.1186/s13011-018-0190-1

 

Authors’ response: As explicitly cited in the current manuscript on page 2 Line 52, the current manuscript is part of the same project with the previously published article found “10.1186/s13011-018-0190-1”. Hence, the table referred in the current manuscript is already published in the previous work. The current manuscript was originally submitted to International Journal of environmental and Public Health (IJEPH) and transferred to Challenges journal along with the authors’ response to the comments from the previous journal. The manuscripts share the same description of study participants. Therefore, the reviewers in the previous journal have commented that if it is published elsewhere, better to cite it than including it again in the current manuscript just to avoid duplication. The conversation with the previous reviewers is provided below. However, if the need to explain it more seems required, we well be hearing from you.

 

Reviewers’ comment:  Table 1 is the same one used by the authors in a previous publication. I suggest checking with the editors of that previous publication whether this does not break any copyrights.

Authors’ response: Thank you for the suggestion, It sounds that publishing the table, which is already published elsewhere may cause unnecessary replication. Hence, we would like to hear more from reviewers and the editor of the current manuscript that if we can refer to/cite the previously published table from the previous publication indicating the exact page where it is found. If this doesn’t seem sound, we may replicate it in consultation with the editors of the previous publication. From our point of view the former option sounds better. We better rephrased it as “The table that summarized the scocio0demographic characteristics of the participants is published elsewhere (13 p.3 )”. Hence, we preferred to avoid submitting it as a table to the current submission.

 

Overall, as authors of the current manuscript, we have made necessary revisions to address the reviewers’ comments and suggestions. We also conducted a thorough revision on the reference section to make the current manuscript informed from the recent outmost and quality evidence. Old references are removed and replaced by newer ones and duplicated we minimized the number of references with similar findings in our citation. We have also verified the studies cited in the manuscript. 

Reviewer 3 Report (New Reviewer)

The article describes the circumstances under which students at Mekelle University (Ethiopia) use psychoactive substances. A qualitative study is conducted through focus groups and in-depth interviews. Drug use occurs at specific celebrations and events, where more than one drug is used (poly-drug use). An interesting aspect is that the use of these substances takes place close to the campus, and even on campus. Another point to highlight is that specific interventions are proposed to reduce drug use.

Aspects to be improved. In my opinion, there are some issues that would be advisable to correct before publishing the article:

1.            In section 1 (Background), second paragraph, it discusses psicoactive drug use among university students around the world. The quotes (numbers 7, 8 and 9), correspond to a study conducted in Russia in 2013, another in Nigeria (2017) and another in the same country with which the comparison is made (Ethiopia). Please include some more current citations and from other countries. It would be interesting to know if the abuse of psychoactive substances at Mekelle University in particular and in Ethiopia in general is higher or lower than the percentage reported in other universities in other countries, with updated data.

2.            The section "3.1 Socio-demographic status of participants", should be included in section 2 (Methods and participants), not in section 3 (Results).

3.            Please include a table summarising the socio-demographic characteristics of the participants, including any relevant data (e.g. age, gender, socio-economic status, etc.).

Author Response

Reviewer 3 comment # 1. In section 1 (Background), the second paragraph, it discusses psychoactive drug use among university students around the world. The quotes (numbers 7, 8 and 9), corresponding to a study conducted in Russia in 2013, another in Nigeria (2017) and another in the same country with which the comparison is made (Ethiopia). Please include some more current citations and from other countries. It would be interesting to know if the abuse of psychoactive substances at Mekelle University in particular and in Ethiopia in general is higher or lower than the percentage reported in other universities in other countries, with updated data.

Author's response: The other reviewers also suggested the need to indicate the current topic, psychoactive substance misuse, in the context of the major challenges in the today’s globe.  As authors of the current manuscript, we have realized that this is crucial to improve the background section. Accordingly, we have thoroughly revised the first and second paragraphs of the background section. Along with. we have updated the references (ref #1-9), removed reference which with less relevant to the topic in all the whole body of the manuscript. To indicate that psychoactive substance misuse is a problem that university students from everywhere faced, we have included references from diverse countries of the world. We hoped the revision would satisfy the reviewers of the current manuscript.

Reviewer 3 comment # 2. The section "3.1 Socio-demographic status of participants", should be included in section 2 (Methods and participants), not in section 3 (Results).

Authors’ response: We accept that the socio-demographic characteristics of the participants should also be indicated in the methods section. the table that summarizes socio-demographic characteristics of in the current manuscript is already published in the previous similar work (but with different objective. As the raised by reviewer 2, prefer to cite the previously published manuscript to avoid duplication of already published material (table). Hence, we have provided citation it (#12) and we have provided DOI of the published paper ((available at DOI: 10.1186/s13011-018-0190-1).

 

Reviewer 3 comment # 3. Please include a table summarising the socio-demographic characteristics of the participants, including any relevant data (e.g. age, gender, socio-e)

 Authors’ response: We have included age, sex and college of the participants for the interviews and female and male FGDs are organized separately and this is indicated.

Round 2

Reviewer 2 Report (New Reviewer)

The paper can be accepted since it has been completely edited and rewritten.

Check spelling and punctuation throughout all the text.

Author Response

Thank you for the suggestion to check spelling and punctuation throughout the text. As per the suggestion we have made extensive revisions. We used a native English speaker edition supplemented by a software-assisted grammar and spelling checker. The modifications made are indicated in track changes. We hope the revision we made will satisfy the expectation of the reviewers.  

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Introduction
- The introduction offers the reader the necessary context to place the study. 

- The authors mention that psychoactive substance misuse has increased (Line 46). The authors cite two studies that explored the prevalence of alcohol and tobacco, respectively. The authors must provide a comparison point to claim increased misuse of substances.

Materials and Methods
The authors provide a good description of the methods used to collect and analyze the data. 

- This section is missing a description of the recruitment process

- The authors mention that the focus groups participants underwent face-to-face interviews. It is unclear whether the focus group participants were then invited to the interviews or the focus group discussions took place in person. Please, clarify.

- The authors mention that investigators asked follow-up questions (Line 118). Please, provide some further explanation about how these questions were asked, e.g., by email or a follow-up interview? Were they only directed at those who participated in the individual interviews, the focus group discussions, or both?

- The authors mention that data from FGD and KIRs interviews were assessed for similarities and variations. Is there a reason why individual interviews were not included in this comparison?

- Table 1 is the same one used by the authors in a previous publication. I suggest checking with the editors of that previous publication whether this does not break any copyrights.

- This table has two grammatical errors in the description of the last two participants ("substance non-user user & substance non-user user student)

- The authors mention that each audiotaped interview was reviewed multiple times, transcribed verbatim, and imported into ATLAS.ti (Line 131-2). Was the same done with the focus group discussions?

- The authors explain that the transcripts were coded a second time against the generated codes (Lines 138-8). I suggest the authors provide some further explanation about the purpose of this second round of coding.

Results
- The first theme is "socio-demographic status of participants." This theme describes the psychoactive substance use as reported by the participants. If the authors consider it appropriate, I suggest having first a description of the socio-demographic status of participants here (currently described in the material and methods section) and then having "psychoactive substance use" as potentially the first theme.

- It is unclear whether all participants lived on campus, e.g., there is a mention of dorms (Line 198), students being on campus at 9 pm (Line 175, and students scoping out places around campus to use substances (Line 158). Please, clarify

- All quotes used at the beginning of theme 3.1 explain that students tend to use alcohol after Khat chewing and tobacco smoking or that alcohol comes after all substances. But, the authors also explain that mostly, alcohol use proceeds all other substance use (Line 149-150). Did the authors mean "precedes" in Line 150? If yes, could the authors explain this discrepancy?

- The authors also explain that where money and distress are not a concern, students often chew Khat and drink alcohol in small groups. In contrast, they smoked alone (Lines 156-7). Is this also applicable only to situations where money and distress are not a concern? What do the authors mean by distress?

- Some claims may benefit from further descriptions. For example, the authors explain that students reported using more than one substance (Line 146). Was this the case with all students participants who used substances? Was there a most common combination reported in the conversations? Also, the authors explain that poly-substance using students drank alcohol after chewing Khat, smoking hashish, and cannabis (Lines 162-3). Was this always the case? 

- I suggest the authors clarify in Line 244 that shisha is a term used to describe cannabis. Also, could the authors explain that Angada and Med'a are to an international audience?

Discussion
- The statement "Students used Alcohol, Khat, Cigarette, cannabis (locally called "Shisha") and hashish concurrently" feels like a very loaded statement. Perhaps the participants who used these substances use them concurrently. Also, did all participants who used these substances use them concurrently?

- The authors suggest that the lack of academic requirements or classes promoted substance use. (Lines 283-4). This seems unlikely, as it is probably not the case with all students. Keeping all students busy with additional academic work, and thus, reducing their free time, may add additional stressors to students who use and don't use alike. Plus, it may disrupt a necessary work-life balance. 

- The authors found that some students smoked early in the morning (although this is presented as something done by Ethiopian University students, which is unlikely the case for all students) (Line 298-9). This is extremely common among people who have developed nicotine use disorder. As the authors suggest, it does speak about the need to provide additional support to these students. 

- The authors also mention that students' main place of substance use is on campus (Line 314-5). Still, as mentioned above, it is unclear to the reader whether these students indeed live on campus. 

Conclusion
- The results do not support the conclusion that "Free time during University encourages University students to misuse psychoactive substances" (Lines 323-4). It is improbable to be the main driver behind substance misuse. 

- Similarly, to claim that celebrations predispose substance misuse is an equally too loaded claim (and not supported by the results). Celebrations might have precipitated substance use (and potentially misuse) among some students who participated in the study.

Reviewer 2 Report

The study aims to assess the environmental risk factors associated with the use of psychoactive substances within an Ethiopian university. This is a very important topic but I have major concerns with this paper.

General Major comments

1. The paper seems so local, not just in its research, but also in the writing, that I wonder if it may not be best suited for a national paper. I do not think it is a good fit for an international journal except they do some major revisions specifically the writing context. The background and discussion is written in the context of Ethiopian universities with no reference to why those schools are selected (e.g. largest schools, schools with highest substance use prevalence etc), so it is hard for a non-familiar reader to understand the relevance of this paper outside Ethiopia. The authors need to place this paper in the context or substance use across universities in general not just Mekelle or local universities. Use reviews from other African countries or globally. How do these prevalence figures compare to substance use in other universities globally? So are these Mekelle numbers high in comparison with others etc? Overall, the authors should consider submitting to a national or local journal.

Introduction

2. Lines 65-72. While I understand why this topic is important, I do not understand how the aim of this paper differs from the studies reviewed from lines 54-64. The authors need to differentiate their study for the reader to understand. This is not a novel study so they need to let the reader understand its importance.

Methods

3. The Methods section has some major flaws that do not allow for replication. For example, the authors say the sample was purposively selected by certain characteristics (lines 86-87) but from how did they meet these people? Was there a database? Was there a snowball method involved? If yes who was the primary contact etc.
4. Also, the roles of the people selected is very unclear. For example, why were non-users selected? What is the KIR approach? What qualifies them as KIRs using the selected characteristics in lines 86-87? At first glance, it seems like these are all informants but again the results seem to state that they reported use, how did non-users report use? Who are proctors? How did you decide on a shop owner and a bar owner?
5. Where are semi-structured guides for interviews or focus groups? There was an attached document but it was in a foreign language making it impossible for the reader to follow.

Results

6. The results need to guide the reader. Currently, it reads as a long list of texts from the respondents, specifically subsection 3.2, and some descriptions don’t match the transcribed text. For example, lines 173-174 talk about where they buy from but I don’t see the purpose of lines 175-177 that comes right after, since it talks about timing.
7. What do the authors want the reader to take away from this section? For example, some aspects within 3.2 talk about timing while some talk about causes e.g. boredom, while some about who uses e.g. final-year graduating students, and some where they get from bars located in the surrounding towns. There’s a lot going on in that section, so the authors need to revise and guide the reader properly.
8. Also, probably the authors can structure the results from the different sample groups e.g. user, non-user etc, maybe it will throw more light on their different roles.

Minor comments

1. Can the readers provide a brief description of Khat specifically its risks compared to alcohol and tobacco since these are the main products focused on.
2. Lines 80-82 – was this study done in collaboration with the center as I can see them benefitting a lot from these results. S, does the center have annual reports that informed this study? I’ll assume there should be some sort of connection between this center and the study. Can the authors clarify the role of the center in this study
3. All abbreviations should be spelled out inside the text (not at the end of the paper only) before use.
4. Line 50- what year?
5. Line 106 - why do we have to know the sex of the researchers?