Research Thesis Personality Traits, Interpersonal ...

Research Thesis

Personality Traits, Interpersonal Difficulties, and Mental Health

Problems in Somalian Khat Addict: An Intervention Study

Participant’s Name: Abdifatah H. Daud

Participant ID: 15005166004

Supervisors’ Name

Dr. Zahid Mahmood

Institute of Clinical Psychology

University of Management and Technology

Lahore

2019

Declaration from Scholar

I, Mr Abdifatah H. Daud Roll No. 150051466004 PhD Scholar, in the subject of

Clinical Psychology session 2015 – 2019, hereby declare that the matter printed in the

thesis titled “Personality Traits, Interpersonal Difficulties, and Mental Health

Problems in Somalian Khat Addict: An Intervention Study” is my own work and has

not been printed, published and submitted as research work thesis or publication in any

form in any university research institution etc in Pakistan or abroad.

Date: ----------------------------- Signature of Deponent

Declaration Certificate from Supervisor

It is to certify that the research work described in this PhD dissertation entitled

“Personality Traits, Interpersonal Difficulties, and Mental Health Problems in

Somalian Khat Addict: An Intervention Study” is the original work of the author and

has been carried out under my direct supervision. I have personally gone through all its

data, contents and results reported in the manuscript. Furthermore, to the best of my

knowledge, all the data collected and analyzed are genuine and original. I further certify

that the material included in the dissertation has not been used partially or fully, in any

manuscript already submitted or is in process of submission in partial or complete

fulfillment of the award of another degree from any institution. I also certify that the

thesis has been developed under my supervision according to the prescribed format and I

endorse its evaluation for the award of PhD degree in accordance with the prescribed

procedure of the university.

__________________________________

Supervisor

Prof. Dr. Zahid Mahmood

Director of Institute of Clinical Psychology,

University of Management & technology

Lahore, Pakistan

Certificate of Approval

Accepted by the Faculty of the Institute of Clinical Psychology, University

of Management and Technology, Lahore in partial fulfillment of the

requirements for the degree of PhD in Clinical Psychology

Prof. Dr. Zahid Mahmood

Supervisor

Prof. Dr. ----------.

External Examiner

Prof. Dr. Zahid Mahmood

Director of Institute of Clinical

Psychology, University of

Management and Technology

Date: ___________

Dedication

I would like to dedicate this work to

My Late Father

Who introduce me to have hunger for the knowledge.

Table of Contents

Page No

Acknowledgement i

Abstract ii

List of Tables iii

List of Figures iv

List of Appendices v

Chapter I Introduction 1

Chapter II Review of literature 15-53

Introduction 15

Prevalence of Khat chewing 21

Chemistry and pharmacodynamics of Khat 24

Problems related to Khat using 28

Risk factors for developing using 35

Model of the study 43

Addiction treatments 43

Rationale 49

Research questions and hypotheses 51

Chapter III Method 54-71

Settings 44

Section I: Process of developing KIDS 55

Section II: Prevalence study 59

Section III: Comparative study 61

Section IV: Intervention study 65

Chapter IV Results 72-119

Section I: Psychometric properties of KIDS 73

Section II: Prevalence study 81

Section III: Comparative study 88

Section IV: Intervention study 109

Summary of results 118

Chapter V Discussion 120-129

Implications 129

Limitations and suggestions 131

Conclusion 131

References 134-161

Appendices 162-180

i

Acknowledgements

I would like to thank my father for his inspiration and support for seeking

knowledge throughout my life. He encouraged me to strive for excellence in education

and continued doing it as long as I am alive. Thank him I could not do this work without

his wisdom in my mind. Thank my mothers who don’t understand my project much, but

at the same time use to ask me about it and gave me emotional support on every step of

this work. Thank as well to my Uncle Dr. Nageeye, my brother Dr. Gahayr, and the entire

family for the unconditional support that they gave me throughout this challenging time.

I don’t have words to express my sincerest and special gratefulness to my teacher

and supervisor Dr. Zahid Mahmood, Director of Institute of Clinical Psychology,

University of Management and Technology, Lahore, for believing me, giving me the best

guidance, and support me in any aspects throughout this work. Because of him, I learned

a lot, and my way of thinking have changed. I want to thank my teacher Dr. Sadia Saleem

for the excellent guidance that she gave me during this tough work.

I would also like to thank my colleagues, Mohamed Hashi, Ilyas Xusein, Muna

Boqore, Amin Xassan, Xamda Abdinasir, Idiris Garas, and Mahmood Ilmi, for helping

me in collecting data that was difficult doing without them. Likewise, thank my

classmates for the cooperation and assistance they give me throughout the Ph.D.

program. I would like to acknowledge as well for the administrations of the Amoud

University Borama for cooperating with me and allowing me to collect data from its

students. Also, thank students who accept to participate in this study and followed well

the instructions that I gave to them.

ii

Abstract

Khat abuse is endemic in East Africa and the Arabian Peninsula. It is a leaf of a tree that

is chewed for euphoric effect and may cause many psychosocial problems for the

individual who consumes it, as well as, the community at large. The present study

intended to find out the prevalence of Khat use among male university students with the

age rage of 18 to 25 ((M=21.44, SD=1.71); the difference between Khat users’ and non-Khat

users’ on personality traits, interpersonal difficulties, and mental health problems; and the

differential effectiveness of Cognitive Behavior Thearpy (CBT) and Psychoeducational

Therapy (PET) on the habit of Khat chewing and its associated problems. The current

research comprised four studies. In study I, a culturely sensitive, valid and reliable

measure was developed to assess interpersonal difficulties namely personal related and

Khat related. Study II comprised to determine the prevalence of Khat users among

university students. Study III, Khat users and non-Khat users were compared on the basis

of personality traits, interpersonal difficulties and mental health problems. Final study,

effectiveness of CBT and PET on Khat abuse was accomplished.

Starting with the prevalence study, the results revealed that, nearly 17% of

Amoud university students were currently Khat chewers, while around 30% were lifetime

prevalence of Khat users. Having a father or siblings or friend who chews Khat, and

having smoked anytime in your life were associated with a lifetime prevalence of Khat

chewing (p<0.001). It was also found that students who use Khat scored high on

neuroticism (p<0.001) and psychoticism (p<0.01), and tend to experience more

interpersonal difficulties and mental health problems (p<0.001) as compared to those

students who did not use Khat. Finally, the CBT group showed significant decrease of

Khat chewing behavior and associated problems as compared to PET group (p<0.001).

Inconclusion, using Khat is associated with Neuroticism and Psychoticism, and

experiencing interpersonal difficulties and mental health problems. It also recommended

CBT over PET for dealing Khat abuse and related problems.

iii

List of Tables

Table No Page No

Table1…………………………………………………………………………65

The Factor Structure of 33 Items of Khat Interpersonal Difficult Scale (KIDS)

with Varimax Rotation

Table 2…………………………………………………………………………66

Eigen Values and Variance Explained by Two Factors (Personal Related and Khat

Related) of Khat Interpersonal Difficulties Scale (KIDS)

Table 3…………………………………………………………………………67

Cronbach Alpha of Total Items of Khat Interpersonal Difficulties Scale (KIDS)

and the two Factors (Personal Related and Khat Related) Separately

Table 4…………………………………………………………………………68

Summary of Inter-correlation, Means, and Standard Deviations for Scores on Two

factors (Personal Related and Khat Related) of Khat Interpersonal Difficulties

Scale (KIDS)

Table 5…………………………………………………………………………70

Frequencies and Percentage of Prevalence Study Characteristics of the

Participants (N=1153)

Table 6…………………………………………………………………………72

Prevalence of Chewing Khat among Undergraduate Amoud University Students

of the Participants (N=1153)

Table7…………………………………………………………………………73

Frequencies and Percentage of Patterns of Chewing Khat in among the Current

Khat Chewer Students of Amoud University of a Participants (N=1153)

Table 8…………………………………………………………………………74

Factors Associated with Life Time Chewing Khat among the Students of Amoud

University of the Participants (N=1153)

Table 9…………………………………………………………………………76

Means, and Standard Deviations of Age of the Participants Khat Users (n=247),

and Non-Khat Users (n=94)

Table 10………………………………………………………………………..77

Frequencies and Percentage of Four Levels of Undergraduate University of the

Participants Khat Users (n=247), and Non-Khat Users (n=94)

Table11………………………………………………………………………….78

Frequencies and Percentage of Patterns of Chewing Khat of Only Khat Users

Group of Participants (n=247)

Table 12…………………………………………………………………………80

Means, Standard Deviations, t-test and p-values of Comparing the Khat Users and

Non-Khat Users on the Two Factors (Personal Related and Khat Related) and

Total of KIDS, Three Factors (Depression, Anxiety, and Stress) and Total of

DASS, and Four Factors of EPQRS (Extroversion, Neuroticism, Lie Scale, and

Psychoticism) of the Participants (N=341)

Table 13…………………………………………………………………………82

Hierarchical Regression Analysis of Predictors of Interpersonal Difficulties of

Khat Users of Participants (N=247)

Table 14…………………………………………………………………………84

Hierarchical Regression Analysis of Predictors of Mental Health Problems Users

of Participants (N=247)

Table 15…………………………………………………………………………86

Mediation Effect of Interpersonal Difficulties on the Relationship between

Personality Traits and Mental Health Problems of Khat Users Participants

(N=247)

Table 16…………………………………………………………………………89

One Way Analysis of Variance for Frequency of Chewing Khat the Two Factors

(Personal Related and Khat Related) and Total of KIDS, Three Factors

(Depression, Anxiety, and Stress) and Total of DASS, and Four Factors of

EPQRS (Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the

Participants (N=247)

Table 17…………………………………………………………………………91

One Way Analysis of Variance for Chronicity of Chewing Khatand the Two

Factors (Personal Related and Khat Related) and Total of KIDS, Three Factors

(Depression, Anxiety, and Stress) and Total of DASS, and Four Factors of

EPQRS (Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the

Participants (N=247)

Table 18………………………………………………………………………93

Means, Standard Deviations, t and p-values of Pattern of Using Khat (Alone and

In-group) on the Two Factors (Personal Related and Khat Related) and Total of

KIDS, Three Factors (Depression, Anxiety, and Stress) and Total of DASS, and

Four Factors of EPQRS (Extroversion, Neuroticism, Lie Scale, and Psychoticism)

of the Participants (N=247)

Table 19………………………………………………………………………94

Means, and Standard Deviations of Age of the Participants CBT Group (n=20),

PET Group (n=20)

Table 20………………………………………………………………………95

Frequencies and Percentage of Patterns of Khat Chewing between CBT Group

and PET Group in Experiment Study of the Participants (N=40)

Table 21………………………………………………………………………97

Means, Standard Deviations, t and p-values for Comparing CBT Group and PET

Group on the Basis of Khat Interpersonal Difficulties and Mental Health Problems

of the Participants (N=40)

Table 22……………………………………………………………………….99

Chi-Square Comparison between CBT Group and PET Group on the Basis of

Patterns of Khat Chewing after Received Treatment

iv

List of figures

Figure 1: Scree Plot Showing Extraction of factors of Khat Interpersonal Difficulties

Scale (KIDS) of the participants (N=200)

Figure 2. Simple Mediation Analysis Model for Interpersonal Difficulties as Mediator for

Relationship between Neuroticism and Mental Health Problems (N=247)

Figure 3: Simple Mediation Analysis Model for Interpersonal Difficulties as Mediator for

the Relationship between Psychoticism and Mental Health Problems (N=247)

Figure 4: Differences of CBT group and PET group based upon mental health problems

before and after the therapy (N=40)

Figure 5: Differences of CBT group and PET group based upon interpersonal difficulties

before and after the therapy (N=40)

v

List of Appendices

A: Demographic Form of Scale Development

B: Questionnaire of Prevalence Study

C: Demographic Form of Comparison Study

D: Demographic Form of Intervention Study

E: Khat Interpersonal Difficulties Scale (KIDS)

F: Depression Anxiety Stress Scale (DASS)

G: Eysenck Personality Questionnaire (Short Form-EPQ)

H: Inventory of Interpersonal Problems (IIP-Short Form)

I: Permission to use IIP Shor Form

J: Written Inform Consent for Intervention Study

K: Permission from Amoud University for Conducting Prevalence Study

L: Institute Ethical Committee Approval

M: Plagiarism Report

1

Chapter I

Introduction

The conception of psychoactive substance has a long root and has been present

since the beginning of humanity. It is a global phenomenon and every society is dealing

with its associated problems. It is estimated that approximately 4000 plants produce

psychoactive substances, of which 60 of these drugs were constantly used throughout

history, somewhere in the world, with the predominant ones being cannabis, opium, coca,

tea, coffee, tobacco, and alcohol (Numan, 2012). These substances are highly addictive

and cause individuals to have a strong desire for its use. Addictive behaviors (primarily

alcohol consumption, tobacco smoking, and unsanctioned psychoactive drug use)

contribute immensely to the global burden of morbidity and premature death. The

problems of addictive behaviors include high economic burden on the people through

high cost on healthcare, public safety, crime, lost productivity and other social costs

(Gowing et al., 2015).

The world’s adult population suffering from an alcohol use disorder is estimated

to be 240 million (7.8% of men and 1.5% of women). Alcohol is also estimated to cause

257 disability-adjusted life years lost per 100,000 populations. It is also estimated that 1

billion people, 22.5% of the adults in the world are smokers of tobacco products (32.0%

of men and 7.0% of women). Tobacco is estimated to cause an estimated 11% of deaths

in males and 6% of deaths in females each year. With the global prevalence of 3.5 %,

Cannabis is the most prevalent ‘unsanctioned psychoactive drugs’ others each being at

less than 1%; the prevalence of injection drug users being 0.3% of the world’s adult

population (15 million). It is estimated that the unsanctioned psychoactive drugs cause 83

2

disability-adjusted life years lost per 100 000 populations. Though it was not possible to

get the estimates of gambling problems globally, a prevalence of 1.5% was reported in

countries where it has been assessed (Gowing et al., 2015).

Each substance abuse is concentrated some part of the world where its natural

form is available (Numan, 2012). For example, cocaine is found in South America

(Ehleringer, Casale, Lott, & Ford, 2000) cannabis in Central Asia and the Indian

Subcontinent (Elsohly, 2007). Similarly, Khat is popular in an area that extends from

eastern to southern Africa and some parts of Arabian Peninsula. Khat is the name denoted

to a dicotyledonous evergreen shrub of the family of Celastraceae. Cathedulis is the

scientific name of Khat and has other names: qat, chat, qaadka, kus-es-salahinmiraa,

tohai, tschat, Abyssinian tea, African tea, African salad, and brown cows. Khat (Catha

edulis) is a plant that usually grows on high altitudes in the eastern and southern parts of

Africa, as well as some parts of Arabia. It originated from Ethiopian highlands, but at

present, it also grows in Yemen, Keyna, Tanzania, Uganda, Malawi, Zambia, Zimbabwe,

Congo, Madagascar, and Afghanistan (Jibril & Yusuf, 2012).

The origins of the Khat plant are somewhat mysterious, and much of what has

been said about the early history of its use is derived from oral narratives. The historical

evidence for the beginning of Khat use suggested that the practice came from the

southern Red Sea area (Ethiopia and Yemen) before the mid-fourteenth century. Khat

seems to have been used first in the liquid state prepared from dried leaves, but its effect

is weak comparable with that of coffee. It was later realized that the drying process of

leaves makes less of its properties, and that is how the habit of chewing the green leaves

3

started. For many hundreds of years, the custom of chewing Khat leaves has been

practiced for the resulting central stimulant effects (Al-Hebshi & Skaug, 2005).

Khat leaves or twigs are chewed for stimulant and euphoric properties and have

the same chemical structure, however with a lesser effect than amphetamine. It contains a

psychoactive substance called cathinone, which produces central nervous stimulation

analogous to amphetamine. It has many chemical compositions that make an impact on

different parts of the human body. These chemicals increase the function of some areas of

the body, while they decrease that of some other areas. However, the most psychoactive

element of Khat is Cathinone, which has a broad range of effects on the central nervous

system. Like other stimulant drugs, Cathinone increases energy, alertness, and self-

esteem. It enhances social interactions and artistic abilities that are associated with

generating ideas. In addition to these, Cathinone decreases the need for sleep, food, and

sex. Finally, all these effects are desirable and make its use more prevalent (Wabe, 2011).

Khat chewers report personal proficiencies in an affirmative way when taking

small quantities. They refer to a sensation of happiness, a sensation of euphoria, pleasure,

increased energy levels and alertness, increased the capability to focus, development in

self-confidence and a rise in libido. However, after chewing stops, unfriendly aftermaths

tend to take over the experience: sleeplessness, emotionlessness, lack of focus and low

mood. Some chewers also experience disagreeable effects in the course of the chewing

course, anxiety, pressure, agitation and hypnagogic hallucinations (Basker, 2013;

Magdum, 2011).

Khat also interferes with many aspects of the normal functioning of the

individual’s life. It has an impact on the physical, psychological, social, and financial

4

conditions of the individuals. As for physical problems, Khat causes gastritis,

constipation, loss of appetite, malnutrition, and teeth deterioration or darkening (Basker,

2013). Likewise, it elevates blood pressure and can cause hypertension, cardiovascular

diseases, obesity and many more problems (Al'Absi et al., 2013; Al-Motarreb, Al-Habori,

& Broadley, 2010; Getahun, Gedif, & Tesfaye, 2010). Moreover, there is an increase in

cardiovascular reactions to physical exertion under the influence of Khat which possibly

can lead acute cardiovascular complications, mainly in aging people. Khat also affects the

respiratory center and can cause broncho dilation, which can explain the sensation of the

well-being of asthmatic users (Al-Motarreb, Al-Habori, & Broadley, 2010; Sallam et al.,

2018). It also relaxes the wall of the bladder and creates closure of internal sphincter.

Furthermore, it may be a source of urine retention and a decrease in maximum urine flow

throughout the track (Gashawa & Getachew, 2015). With regard to sexual behaviors, the

users of Khat experience low libido and spermaturia that can lead to diminishing sexual

performances. Consuming Khat during pregnancy can lead to the premature birth of the

child (Mwenda, Arimi, Kyama, & Langat, 2004; Nakajima et al., 2017).

The consumption of Khat is also related to the risk of experiencing psychiatric

problems such as insomnia, lethargy, and hopelessness (Basker, 2013). In some cases, it

reported that the chewers experience a state of mania or hypomania. Moreover, Khat can

cause some psychosis, but yet there are few incidents. Therefore, the relationship

between psychosis and Khat is not clear as yet. Some studies have revealed that chewing

Khat exacerbates the symptoms of psychosis or mania while some other studies

mentioned that using Khat increases the likelihood of developing these disorders.

Likewise, constant Khat intake is associated with increased physical and verbal

5

aggression, as well as violence in general. Aggression and violence result from decreased

serotonin level and its metabolism. A group of WHO experts exposed that the habit of

chewing Khat had a moderate psychic dependence on those people who used it regularly.

Similarly, withdrawal symptoms were seen in individuals who had consumed Khat for an

extended period of time, these symptoms included: lethargy mild depression, slight

trembling, fatigue, and recurrent nightmares (Basker, 2013).

Socially, the habit of chewing Khat has a devastating impact on the family. The

consumption of Khat deteriorates the relationship between husband and wife. This is

mainly because the husband spends most of his time on chewing Khat and this can result

in his coming home late at night. Furthermore, lack of enough sleep and getting up late in

the morning increases the likelihood of unemployment, which sometimes causes the

husband to use the family income to buy khat. These problems escalate the concerns of

the wife about the finances and welfare of the family, which heightens conflict between

the spouses. Additionally, Khat chewing has a tremendous impact on children whose

fathers consume Khat. These fathers spend less time with their kids as they return late in

the night while children are sleeping and they wake up late in the morning after the

children go to school. Some fathers try to fill this gap by chewing Khat at home to spend

time with their children. However, the mood swings that are associated with Khat

consumption make children confused about their father's behavior; happy and talkative at

one time but irritated at another time (Jibril & Yusuf, 2012).

Moreover, anti-social behaviors are more commonly seen during and after

chewing Khat. These behaviors include dangerous driving, noisy Khat selling places, and

large amounts of waste from the trade in Khat. In addition, while searching for the money

6

to purchase Khat, young and unemployed individuals may get involved in fighting,

stealing, and robbery to fund their Khat use. Similarly, regular use of Khat is the reason

for sleeplessness, agitation, and irregularity at workplaces that makes many Somali’s

jobless (Hunter et al., 2012; Warfa et al., 2007). Although some argued that Khat

production was a source of income for many people and the Somali government

generated tax from it, it also creates some significant economic issues in the country.

Since Somalia does not cultivate Khat and instead imports it from neighboring countries,

it was estimated that a semi-autonomous region of northern Somalia (called Somaliland)

spent 30% of Gross Domestic Product (GDP) on Khat. On an individual level, on

average, each person spends six to seven dollars per day on Khat. In addition, the usage

of Khat challenged the efficiency of employees, which decreased the production of the

country and the effectiveness of state institutions (Hansen, 2010).

Khat consumption often is associated with groups in social settings. Only a

minority of individuals frequently chew alone. A group khat session may last for several

hours. Only soft leaves and stems are consumed, and the juice is swallowed with the

saliva. The residue is not spat out right away, but collected in the cheek and usually kept

for the whole period of chewing. The bolus thus accumulated makes a distinct bulge in

the cheek of the chewer. At the time of Khat chewing, plenty of liquids (tea and soft

drinks), are consumed as well. The need for the consumption of liquids is because some

main active ingredients of Khat trigger dryness of the mouth. Often, Khat parties are

organized by well-to-do people, singers, and/or poets are invited, and the drug is

consumed to the sound of a guitar and listening to Somali melodies and poems. Some

chew Khat while working, especially of long-distance truck drivers who use the drug so

7

as to remain awake and increase their effectiveness. Also, some students and academics

use the Khat while studying or working. At the beginning of the Khat session chewers

experience euphoria, feeling of empowered active, and wellness, however as the time

passes by the irritability, stress and emotional instability starts to take over the initial

positive feelings and most of the chewers tend to look nervous and down feeling (Cox &

Rampes, 2003).

Khat was originally used by specific regions in East Africa and the Middle East.

Culture regulated its use and as a result only certain groups like religious leaders,

farmers, and drivers, etc., were allowed to consume Khat for specific times only.

However, Khat became available and widely used in the neighboring countries and the

world including the United States and Europe in the past 30 years due to changes in the

society of the originating countries. Immigrants from East Africa and the Middle East

make up the majority of those who consume it in the western world. The development of

synthetic forms of Khat’s active component has increased its availability and transporting

globally (El-Menyar, Mekkodathil, Al-Thani, & Al-Motarreb, 2015).

Chewing Khat has a strong influence on the cultural and social aspects of the life

of the communities indulging in it which is attributed to its effects of inducing pleasure

and its stimulating effect. Khat has many functions, but the most important one is its

function as an information exchange medium, where friends meet, news is exchanged,

discussions are taken part, and plans and decisions are made. The information exchange

is highly personal and may be related to the individual’s status in the community

(Abbink, 1992).

8

Despite the fact that Khat is known as ‘the flower of paradise’ by some Muslims,

heavy penalties like those for opium or cannabis are imposed on those who use Khat or

possess it, by some countries in the Middle East, such as Saudi Arabia. Although only

alcohol is mentioned in the Koran to be prohibited, intoxicants other than those

prescribed for medical reasons are forbidden under the Islamic faith. However, even

religious scholars use Khat, which might be because, rather than opium and cannabis;

Khat does not deliver serious antisocial behavior, and it is similar to less extent

amphetamine or caffeine-type substances. A study that took place in Butajira, Ethiopia,

where khat use is lawful, demonstrated that 80% of chewers utilized Khat to pick up a

decent level of concentration for their prayer, to encourage contact with God and to

debilitate them from criminal exercises (Alem et al., 1999).

Like other addictive substances, habit of chewing Khat is also effected by the

social changes. For example, the past few decades the utilization of Khat has expanded

significantly in Somalia. Prior to the civil war, Khat was, for the most part, chewed on

Thursdays or Fridays, and in connection to specific customs, for example, weddings,

funerals, religious social occasions or readings (e.g. Maulids), and on events when it was

needed to remain awake such as working at night or getting ready for exams. In light of

the war, the socio-social standards that used to manage the utilization of khat ceased to

exist, or possibly they have been drastically changed, with more of the male population

using khat regularly. Not only has the chewing of Khat increased, but also, the utilization

of yesterday's khat (berixi), chewing khat outside private homes, the usage of Khat before

lunch, and more women and adolescents chewing Khat. The utilization of khat is

widespread to the point that it influences the financial and political existence of

9

Somaliland (the semi-autonomous region of Somalia), the lives of most people and

families, and socio-cultural value, practices, and identity (Hansen, 2010).

Khat is an interesting issue in Somalia with non-chewers regularly scrutinizing

and chewers safeguarding it (Anderson et al., 2007; Anderson & Carrier, 2006). Critics

consider it to be the most challenging of the development of the country, while users

regularly find it to be a Somali custom that has both positive and negative side. The

critics of khat are mostly coming from female politicians and women in general who

contend that khat has decreased the ability of Somali men and prompted the neglect their

kids and abuse of their wives. The international community has also criticized khat, by

saying that it leads to extreme burden on the economy and hampers the arrangement of a

proficient administration, whereas Islamic scholars affected by Wahabi translations of the

Quran contend that khat is haram. Although, chewing Khat became epidemic in Somalia,

yet little is known about its scope and impact (Hansen, 2010).

Few progress has been made by the definition of problematic khat use as

compared to the other substance abuse. Problematic khat use was associated with

increase frequency of chewing khat, spending khat for longer sessions, using large

amount, withdrawal experience, and experiencing harm related to khat use. However, the

most indicator of problematic khat use is chewing khat on an average 3 or more times a

week and use other substance during or after khat chewing (Mihretu, Nhunzvi, Fekadu,

Norton, & Teferra, 2019).

Many factors contribute to the development of addiction including chewing Khat

such as genetics, personality traits, and environmental factors (Marlatt, Baer, Donovan, &

Kivlahan, 1988). However, personality traits are the most important predictor of the

10

development of addiction, because they mediate the genetic and environmental factors

(Amirabadi et al., 2015). The personality traits that are linked to addiction are

impulsivity, sensation seeking, valuing nonconformity, social alienation, heightened

stress and lack of coping skills, low frustration tolerance, neuroticism, psychoticism, and

many more (Singh, 2012). This does not mean that every person that has these

personality traits will become an addict, but it makes it more likely that the person will

develop an addiction. Moreover, no single factor makes people prone to developing an

addiction, but rather it is a combination of many factors, depending upon the individual

personality traits and their association with addiction and environmental exposures

Moreover, at the society level, each culture has certain norms that monitor and

control the substance use. Excessive use of substance may be initiated at times of rapid

social change, most commonly by people who were hardly exposed to a drug and didn’t

develop protective normative behavior (Westermeyer, 2004). Prior to the whites’ arrival,

a handful of North American Indians were not exposed to alcohol due to its limited

availability. On the western frontier, potent distilled alcoholic beverages became widely

available, and the only model Native Americans had was the drunken comportment of the

frontiersman. The belief that substance abuse problems are related to the extinction of the

traditional culture is common among Native American elders. A low rate of substance

utilization has been seen for bicultural individuals who are alright with the value of the

two cultures, whereas a high rate was seen for the people who do not see the value of

Native American culture (May, 1982). This is also the case for the immigrants moving

from their homeland to a new country. Immigrants are exposed to alien cultural norms

and values when they leave their family protected environment. This is common among

11

Hispanics after moving to the United States. Sensitivity to changes in the level of cultural

assimilation has been portrayed in Cuban American, Puerto Rican, and Mexican

American women. These women are more likely to pick up the dominant society’s

drinking behavior thereby increasing their alcohol use (Abbott & Chase, 2008).

Similarly, drugs are known to be closely related to wars. Drugs were often used

for the preparation of military personnel for combat, for the facilitation of cultural

bonding and for coping with the physical and psychological impact of service, injury and

memory (Golub & Bennett, 2013). That being the case, American veterans from Vietnam

War surprisingly reported a very low heroin addiction rate, after 8 to 10 months

following their return to the United States. The veterans that reported heroin use were

only 10%, and those who reported using heroin more than a weekly for more than a

month were 2%, and those who reported becoming re-addicted, as confirmed by

urinalysis, were a mere 1%. It remained the case in the subsequent two years: only 2%

were re-addicted at follow-up (Hall & Weier, 2017).

Many levels of care are available for substance abuse treatment, such as

outpatient, residential, and inpatient; there are also a number of theoretical orientations to

treating substance abuse. Traditionally treatment has espoused a twelve-step, disease

model of addiction, which has often taken the form of a therapeutic community to work

with addicts. Therapeutic communities typically utilize a peer encounter approach and

reflect the idea that effective treatment involves a massive overhaul of the individual

(Marsch & Dallery, 2012). However, some suggest that cognitive-behavioral techniques

are helpful in teaching specific skill sets, and a motivational component to treatment can

help promote change among reluctant addicts (McHugh, Hearon, & Otto, 2010).

12

Cognitive behavioral therapy (CBT) shows efficacy on single therapy or

combining with other therapy on treating substance use disorders. CBT for substance

abuse combines many treatment elements such as skills building, operant conditioning,

and motivational strategies with the main focus on solving the problem regarding the

potent effect of psychoactive drugs. CBT for drug abuse disorders includes different

interventions, either in combination or isolation and can take place both group or

individual formats (McHugh et al., 2010).

Significance of the Studies

Although Khat chewing and its impacts have become a major topic of discussion

in the country, few studies have addressed it, and most of them are qualitative or

descriptive type studies. Khat Addiction is a neglected area of research because of the

least advance on academic researches of the countries that mostly consume Khat.

Although chewing Khat has become an epidemic since the crisis happened in Somalia,

there are few studies that have addressed Khat related problems. There are demands for

more research in order to understand this phenomenon that has affected many people in

Somalia. So far no scale is available on the interpersonal difficulties associated with Khat

use. In order to have a culturally sensitive scale, the Khat Interpersonal Difficulties Scale

(KIDS) was developed to help with the assessment of Khat use. Furthermore, the last

time in which the prevalence rate of Khat in Somalia was measured was the 1980s, and

the circumstances have changed since then. So, it is of utmost importance to find the

scope of Khat use at present, and for this purpose prevalence rate of Khat Chewing was

determined. The study found empirically the factors that are associated with Khat use

such as personality traits, interpersonal difficulties, and mental health problems. It also

13

established the effectiveness of CBT on Khat use. Together the findings of factors related

to Khat use and the efficacy of CBT will help with the intervention and management of

the phenomena since no study is focused on these areas. Finally, exploring these areas

will have an input on current literature and will guide future researches about Khat use.

Operational Definitions

Khat Addict. Khat addict is defined in this thesis for those individuals who

consume Khat at least once a week.

Interpersonal difficulties. Interpersonal problems are recurrent difficulties in

relating to other people (Horowitz, Rosenberg, & Bartholomew, 1993).

Mental health. Mental health is defined as a state of well-being in which every

individual realizes his or her potential, can cope with the normal stresses of life, can work

productively and fruitfully, and can make a contribution to her or his community (World

Health Organization [WHO], 2014).

Mental health problems. Refers to a wide range of mental health conditions that

affect mood, thinking, and behavior of the person, as well as, interferes the normal daily

life of the individual but not severe enough to distort the reality.

Personality traits. Personality traits are the relatively enduring patterns of

thoughts, feelings, and behaviors that reflect the tendency to respond in certain ways

under certain circumstances (Roberts, 2009)

Aim

To explore the differences between Khat users and non-Khat users on the basis of

personality traits, interpersonal difficulties and mental health problems.

Objectives

14

To develop an indigenous scale for interpersonal difficulties among Khat users in

Somali university population.

To determine the prevalence rate of Khat use among Somali university students

To ascertain the difference between those students who chew Khat and those who

do not chew Khat on personality traits, interpersonal difficulties, and mental

health problems.

To find out the effectiveness of manualized cognitive behavior therapy on Khat

addiction and related problems in university students.

15

Chapter II

Literature Review

Introduction

Khat is defined as a small and evergreen tree whose leaves and shoots are

chewed. Catha-edulis is the scientific name of khat and it belongs to Celastraceae family.

Khat is named differently from country to country such as Marungi (Uganda and

Rwanda), Jaad/Qaat/Chat (Somalia, Ethiopia), Qat (Yemen), and Miraa (Kenya). Khat

can be present in many different countries that extends from the Arabian Peninsula, East

Africa and the long way up to South Africa. Khat is mainly produced in Ethiopia,

particularly in the Harar district, and in Yemen. It is cultivated as well but to a less degree

in the mountain areas of Kenya and some other parts of East and South Africa. Some

reports also mentioned that Khat is available in central Asia, Afghanistan, and northern

Saudi Arabia. It is estimated to grow generally up to 6 m in height, but in an equatorial

area, it can get larger and reach up to 25 m (Odenwald & Al'Absi, 2017). Khat can only

grow at an altitude of 5500-8500 feet or (1670-2590 meters). However, in an area

encountering more ice in winter, the used parts of the plants are either underdeveloped or

killed, and the tree never grows more than 1.5 m. It is cultivated on porches based on

slopes where the trees develop in lines blended once in a while with different crops. The

Khat tree is resilient and is hardly affected by a disease, which makes it possible to live

up to 75-100 years if it is properly cared for. Farmers wait for 3– 4 years before

collecting the leaves (Brooke, 1960; Getahun & Krikorian, 1973; Peters, 1952).

European travelers to the areas of Khat cultivation did not become aware of the

custom prior to the eighteenth century. However, many travelers in the last centuries have

16

mentioned its wide use, after having been revealed by the Swedish botanist Peter Forsskal

(1732-1763). With the massive improvement of transport and infrastructure of road and

railways in nineteenth and twentieth centuries, Khat is being exported from its original

place to the rest of the world. Recently, individuals from the Horn of Africa migrated

massively to Europe and other parts of the world which made Khat available to all over

the world and improved the international market for it. It has also become the economic

backbone of many countries including Ethiopia and Yemen (Odenwald, Klein, & Warfa,

2015).

Many types of Khat have been developed throughout centuries out of local

cultivation habits, regional climate, and environmental conditions. These types of Khat

are different in their appearances and chemical compositions. At the point when plants

become under various climatic qualities, it was discovered that the synthetic profile of

khat leaves was to a great extent controlled by the environment in which it develops

instead of the cultivators (Hailu, Atlabachew, Chandravanshi, & Redi-Abshiro, 2017).

Along these lines, there are around 44 kinds of khat, from 44 distinctive geographic

territories in Yemen alone. Moreover, the taste of khat leaves fluctuates starting with one

kind then onto the next, and relies upon the tannic acid concentrations. The concentration

level of Cathinone in a given type of Khat determines it is potency (Al‐Motarreb, Baker,

& Broadley, 2002). In many occasions, the trading units of Khat are in the form of

bundles; however, the low-quality types can be seen inside the plastic bags in the market.

Chewing fresh leaves is always preferred, but in the past, it was often available in dry

form or powder form, and had been called “Abyssinian tea” or “Bushman’s tea.”

However, nowadays, immediately after harvesting, the shoots and twigs are bagged into

17

bundles and covered with the banana leaves to avoid dryness (Odenwald & Al'Absi,

2017).

Mostly of the time, special gatherings were arranged for the consumption of Khat;

nonetheless, it can be used during work especially physical work in order to make the

user alert and avoid fatigue. Chewing Khat has profound social and cultural roots. Khat

sessions are held for the most part in an afternoon and towards the evening with warm

reception rooms called Majlis in Somalia and Yemen. The visitors sit easily and chew

fresh leaves one after another, and collect them on the mouth to one side of the cheek.

Only the juice is swallowed, and the remainings are spat out. At first, the session is

energetic, and most of the people starts talking, however, as the alarming impacts of khat

begin to work, the session turns out to be more serious and the discussion centers around

one subject at any given moment. The topic of discussion can be religious, political or

current world and local affairs. Following 2 – 3 hours, the session turns out to be calm as

the vast majority of the chewers like to be allowed to sit unbothered, falling into serious

concentrations and imaginations. Regularly, after 4 to 8 hours, individuals begin to leave

the session (Al‐Hebshi & Skaug, 2005).

The effect of Khat differs from one type to another, and the experience is different

from person to person. Similarly, as the majority of drugs used for delight, it is less likely

for the person to miss the effect. The impact of Khat on those who use it can be divided

into the following phases. (1) This phase characterized by the euphoric and energetic

phase which lasts for hours, and it is more enjoyable among the young users. (2) The

users start to have conversation about the important issues with in-depth investigation and

insight into the issue. The session starts with general issues and as the time passes they

18

start talking in pairs and secretly about private matters. (3) In this phase, most of the time

begins around the evening when the users of Khat hate to switch on lights and like to

keep silent. In this phase, the mental state is changing from a favorite imagination to

another. (4) At this stage, the depression starts to appear even though the level of

depression depends on the type and the strength of the Khat consumed. Most of the users

of Khat feel guilt at this depressive state and start thinking not to chew it again. (5) This

phase characterized by sleeplessness, irritability, and loss of appetite, which accompanied

by flight of ideas that make it difficult to concentrate on one point. On the next day, a

feeling of tiredness and having amnesia about the more fabulous ideas of last night

follows. Around the noon just before lunch, the chewers orchestrate about the session of

today, which destroys the promise of last night about the quitting of the substance.

(Al‐Motarreb, Baker, & Broadley, 2002).

The khat session portrayed above is regular for male khat chewers and the

primary activity of the day is chewing. In contrast, the female sessions of Khat chewing

are less frequent and more socially oriented, in which they chew smaller quantities of

Khat within a shorter period than male chewers. When it comes to Somalia, the female

Khat chewers are increasing in the past years, and mostly they chew Khat in hidden

places. The habit is mainly exclusive to old and married women as it is not socially

acceptable for young unmarried women to chew khat (Al‐Hebshi & Skaug, 2005).

The reasons for chewing Khat are varied and can be social or culture-based

activities. It is believed that chewing Khat increases social interactions and makes the

ceremonies, like weddings livelier. Moreover, some people are confident that Khat

chewing enhances religious rituals such as praying and so on, because of its stimulant

19

nature. Khat gives users help to remain alert, boost performance, and upturn the working

ability. Those who work at night use it to prevent sleep and delay fatigue. Students also

chew Khat to help them study more before an exam. Lastly, some chewers say Khat is

helpful for removing a minor illness, for example, body pains, headaches, colds, fevers,

arthritis and as well as depression (Wondemagegn, Cheme, & Kibret, 2017).

Khat chewing by the students increases during exams, at the time students

planning to study long hours (Reda, Moges, Biadgilign, & Wondmagegn, 2012). The

main reason given by students for chewing khat is to concentrate well during study

(Deressa & Azazh, 2011; Kebede, 2002). This is similar to other substance use, where

students consider the use of a substance for enhancing academic performance (Arria &

DuPont, 2010; Carmody et al., 2012). Contrary to the expectations of the students, studies

that examine the relationship between cognitive functions and learning had found an

adverse effect of Khat on academic performance (Colzato, Ruiz, van lair Wildenberg, &

Hommel, 2011). Khat has been connected with decreased academic and cognitive

performance. Khat chewing university students in Ethiopia were found to have a lower

mean Cumulative Grade Point Average (CGPA) as compared to non-chewer students

(Ayana & Mekonen, 2004). Also, low performance on academy has been reported in

students living in Saudi Arabia (Al-Sanosy, 2009). While there has been no proof that

khat influences pass stored information, there is proof that demonstrates its obstruction in

dynamic learning during its usage (Colzato et al., 2011). An examination on

methamphetamine usage has demonstrated a comparable connection between learning

and utilization, where learning is influenced once an individual begins utilizing the

substance (Dean, Hellemann, Sugar, & London, 2012). Khat weaker, but the similar

20

impact as methamphetamine (Brenneisen, Fisch, Koelbing, Geisshusler, & Kalix, 1990).

Additionally, students who have close friends who chew khat will probably utilize it

(Deressa & Azazh, 2011). Chewing Khat typically begins at the adolescence and is

presented by peers (Stevenson, Fitzgerald, & Banwell,1996). Among the young people,

substance use, in general, is influenced by the level of friendship to the individual who

consumes it (Allen, Chango, Szwedo, Schad, & Marston, 2012). Another reason students

begin chewing Khat is a family history of khat conception, and it could be because the

normative of Khat chewing behavior among the family (Deressa & Azazh, 2011).

Since the mid-twentieth century, Khat consumption has significantly changed and

turned out to be more epidemic, which is not confined to the customary and formal

utilization. This is identified with the expanded availability and the increase of the usage

to the group that has customarily not had contact with the substance. It was once

formalized and regulated by social norms, but now, it is characterized by excessiveness,

informality, and uncontrolled habit by some users. This is shown in the utilization of

higher amounts of Khat, longer duration of utilization time, and parallel utilization of

different drugs, such as benzodiazepines or alcohol. While generally the habit of chewing

Khat use to start at 20 years or older, these days, some users begin utilizing it at a

younger age, which made the habit part of youth culture. Moreover, Khat has initially

been a male habit, but currently, there is growing use of Khat by females, and as well as,

pregnant and breastfeeding women (Nabuzoka & Badhadhe, 2000). The khat chewers

generally were mono-substance consumers, but in these days’ combination of Khat with

other substances were reported. The reason to use Khat with another substance is to

modulate the physical or psychological effects of Khat. Most evident is tobacco usage

21

which is firmly connected with khat chewing. Information from Yemeni khat chewers

with and without nicotine use in the UK has driven researchers to speculate on an

upgrade impact (Kassim, Islam, & Croucher, 2011; Odenwald & Al'Absi, 2017).

Prevalence of Khat Chewing

To determine the exact prevalence of khat chewing is challenging, as the

utilization of Khat still to a great extent relies upon socioeconomic, ethnic, and

topographical factors. For instance, in Yemen, the propensity for using khat was once

limited to the northern areas, and to higher classes and specific social gathering, but today

Khat is widely available, and most of the population can afford to buy it. A cross-

sectional study with792 participants that aged 15 years and older have found 81.6% of

lifetime prevalence among men and 43.3% among women; current regular Khat chewer

was found to be 23.6% of the aggregate example (men 31.8%, women 8.9%) (Numan,

2004). In another investigation, among 2500 patients of the Sana'a University dental

school, 61.1% were present khat chewers – 87.0% of men and 12.9% of women (Ali, Al-

Sharabi, Aguirre, & Nahas, 2004). Lastly, in light of the Household Budget Survey 1998,

that was conducted by the World Bank found that Yemenite house spent approximately

9– 10% of their wage on purchasing khat (World Bank, 2001). In 70% of family units no

less than one khat chewer is accounted for and its utilization is about equivalent among

all sections of the population (Milanovic, 2008).

Khat chewing in Ethiopia has customarily been a propensity in the southern and

eastern side of the country which is predominantly Muslim populations, and no

prevalence study is available on a national level that took place in the general population.

A household survey that includes 10468 adults older than 15 years found that current

22

Khat users were 75% of the men population and 35% of the women population in a

predominantly Muslim area called Butajira (Alem, Kebede, & Kullgren, 1999). Another

household survey found current Khat chewers approximately were 40.0% of the men and

18.2% of the women with 1028 adult participants in Adami Tullu district, in southern

central Ethiopia, with mixed religions group (Belew, Kebede, Kassaye, & Enquoselassie,

(2000). Khat usage was likewise more regular among the Oromo ethnic, among Muslims,

married individuals, those with less education, and farmers. Different studies among

Ethiopian secondary school and universities showed that current Khat chewers were

between 17.5 and 64.9% (Kebede, 2002; Reda, Moges, Biadgilign, & Wondmagegn,

2012; Teni et al., 2015; Zein, 1988).

When it comes to Kenya, khat chewing is a habit for some Meru clans

(Nyambene Hills) and Muslims especially in the Somali region in the northern area of the

country. Like Ethiopia, there is no prevalence data available in Kenya for the general

populations. A few investigations of patients in general hospitals of various areas of the

country uncovered a lifetime prevalence of chewing Khat 10.7% for the regions in Kenya

that don’t produce Khat and 29% of the current prevalence rate of chewing Khat in an

area that did produce Khat (Othieno, Kathuku, & Ndetei, 2000). Saudi Arabia, Djibouti,

Madagascar, Tanzania, and South Africa were countries that traditionaly using Khat.

There are some countries that originally not used Khat but started late because of

the spread of the habit. These countries are including Uganda, Rwanda (Anderson,

Beckerleg, Hailu, & Klein, 2007). Khat is nowadays a source of income for many

families, farmers, and the backbone of the economy of many countries. Today, it is

estimated that 10 million individuals use Khat every day (Odenwald & Al’Absi, 2017).

23

As a result of mass migrations, khat consumption spread to the developed countries in

Europe, North America, Australia, and as well as Israel. Khat use in Western nations is as

yet constrained to refugees and immigrant populations (Anderson et al., 2007). In a study

of non-representative sample of 207 Somalis (male 152, female 55) living in London,

Paul Griffiths, discovered 78% (79% of male and 76% of females) with a lifetime history

of khat utilization, 67% had been utilizing it in the week prior to the interview, and 6%

on a daily basis (Griffiths, 1997). Another study with 602 Somalis (324 males, 278

females) in four urban areas in the United Kingdom found that 38% (231) had lifetime

used Khat (male 58%, female 16%) and 34% had been utilizing it in the month before the

interview, and 3% use it on a daily basis (Patel, Murray, & Britain, 2005).

In Somalia, chewing of the substance became a problem in 1960’s. Prior to that

the plant was grown in a very small scale and consumed only in the northern side of the

country. Regarding Somalia, a thirdy year old study of chewing khat in Somalia showed

the north side of the country a 64% of an adult male from general populations frequently

chew khat in contrast with 21% in southern Somalia (Elmi, 1983). The problem was

confined at the beginning only to a small portion of the population like drivers,

musicians, who for the sake of their work need stimulation from the substance. Later, a

large portion of the population from different ages and backgrounds began to chew it; the

only exception was being a child. Different parts of the country started consumption of

the plant at different times, and if we put it in a chronological order, Khat started in the

north-west of the country which is near Harar district of Ethiopia, where the khat

originated. There are no written documents about the real history of khat, but many

factors played a role in why the people in the North-west started chewing Khat first, and

24

one of these factors is because the area is proximal to the area of origin. In former British

Somaliland, the consumption of Khat started after 2nd world war (Elmi, 1983).

A cross-sectional study in northern part of the country (Somaliland), shows that

the use of the substance is more in the people who are ex-combatants 60%, compared to

male civilian war survivors 28% of those who do not experience war 18% (Odenwald et

al., 2005). Recently, evidence came which supports that the business of Khat is overtaken

by different militia’s as a source of funding for their political gain and as well as growing

and export of cannabis and other recreational drugs pose a problem, but the availability of

data is limited. Overall the country has no authorities to tackle the problems of Khat and

other illicit drugs, in fact, the Khat is legally traded by different factions, and there is a

little awareness about the depth of the problem. Alcohol is banned in the country because

of religious beliefs, whereas, most of the other recreational drugs are ignored or get less

attention (Odenwald et al., 2007).

Chemistry and Pharmacodynamics of Khat

A long series of chemical studies were carried out from 1887 to 1978 that focused

on the finding of the psychoactive substance of Khat and the type of alkaloid present in it.

Early studies discovered Cathine and attributed the stimulating effect of Khat to it, and

later work gave introductory confirmation to the nearness of another more dynamic

phenylalkylamine in the new leaves of the plant, perhaps a labile originator of cathine. In

1975, the long-looked-for phenylalkylamine was at last disengaged, portrayed as (7)- an

aminopropiophenone and named as (7)- cathinone (Szendrei, 1980). Later investigations

demonstrated that cathinone is available at a high concentration in the young leaves while

being changed over quickly in the adult leaves into cathine or to a lesser degree, into

25

norephedrine, another phenylalkylamine that represent in Khat. Both cathine and

cathinone are connected fundamentally to amphetamine (Elmi, 1983).

In related examinations likewise brought about the characterization of other

alkaloids called Cathedulins. A study that used liquid chromatography/mass spectrometry

found the presence of 62 Cathedulin alkaloids in a fresh Khat. This discovery supported

the claim that Khat is one of the plants that had complex compositions of alkaloids.

Numerous other substance constituents were distinguished in Khat. Tannins were

observed to be available in extensive amounts that change among various cultivars (7 –

14%). Other elements in Khat incorporate a- and b-sitosterol and friedeline,

triterpenoids, fundamental oils and amino acids, proteins, carotene, calcium, thiamine,

riboflavin, niacin, and iron (Al-Hebshi & Skaug, 2005).

Prolonged and excessive khat use can produce psychological dependence with

similarity to amphetamine dependence type. However, there is limited study and more is

needed to be done on this issue. A number of studies confirmed the potential of Khat to

induce psychological dependence by using the Severity of Dependence Scale (SDS)

which was standardized by Khat dependence (Kassim, Islam, & Croucher, 2010). The

Khat chewers that scored high on the instrument indicated more khat associated

behaviors and had higher khat alkaloid levels in their saliva. A sample taken from

Yemeni Khat chewers in UK showed that 39% of the participants scored high, similar to

severe heroin dependence. Khat chewers on average consume Khat around five hours a

day and six days a week. The severity of Khat dependence indicated increased adverse

effect, low quality of sleep, and more frequency and intensity of Khat use (Nakajima,

Hoffman, & Al'Absi, 2017; Odenwald & Al'Absi, 2017).

26

Little data is available when it comes to the prevalence of Khat dependence as it

is mentioned in the International Classification of Diseases (ICD) or Diagnostic and

Statistical Manual of Mental Disorders (DSM). However, an earlier study conducted in

Ethiopia that used the WHO’s Composite International Diagnostic Interview discovered

5% males and 1.3% females experience lifetime prevalence of Khat dependence as

indicated by the ICD-10 criteria (Awas, Kebede, & Alem, 1999; Odenwald & Al'Absi,

2017). Another study that was carried out on the bases of dependence syndrome as

described by DSM-IV showed 31% of 204 Yemeni origins who live in the UK fulfill the

criteria of dependence according to DSM-IV (Kassim, Croucher, & al'Absi, 2013). On

the other hand, 21 out of 25 chronic psychotic individuals who live in Somalia

(Odenwald et al., 2012) and 33 male Somali refugees Khat chewing in Kenya (Widmann

et al., 2014) fulfill the criteria of dependence as well (Odenwald & Al'Absi, 2017).

Concerning the validity of Khat, the World Health Organization professional

commission on drug addiction interprets Khat as an element with the possibility of

misuse and low addiction. The level of misuse and danger to community health is not

believed to be significant enough to permit universal control, and so, WHO does not

endorse the setting up of Khat. Hence forward, relying on the occurrence of its use and

well-being worries in numerous nations that create the rules of controlling of Khat to be

different from nation to nation. Regardless of the adverse effects, Khat use is legal in its

countries of origin Ethiopia, Yemen, Somalia, Kenya, Madagascar and Uganda

(Magdum, 2011). Though, in EU, Khat is on the list of controlled substances in nations

like Germany, Belgium, Finland, France, Denmark, Greece, Italy, Ireland, Lithuania,

Latvia, Norway, Slovenia, Poland, UK and Sweden. In none of these nations is there a

27

lawmaking difference among diverse kinds of drugs akin to the UK scheme of classes

(A.B.C) or the five schedules shaped by the Controlled Substances Act in the (USA)

(Klein, Jelsma, & Metaal, 2012). However, the pure forms of the compositions of Khat

are scheduled by World Health Organizations. Cathinone which is a substance that is

present on Khat plant is listed as the schedule I, and Cathine as schedule III of the

International Convention on Psychotropic Substances of 1971 and norephedrine is

controlled under the1988 Convention against Illicit Traffic in Narcotic Drugs and

Psychotropic Substances (WHO Expert Committee on Drug Dependence, 2006).

There is enough evidence that supports that cathinone stimulates and releases

serotonergic (5-HT) and dopamine in synapses and at peripheral noradrenergic sites of

neurons. These biochemical characteristics are like those of amphetamines, particularly

sympathomimetic properties. Long time use of consumption of the substance results in

serotonin execution in the basal ganglia of the rat’s brain. The study suggests that

cathinone decreased the level serotonin and increased the production of dopamine which

is believed to be the responsible for aggressive behavior in laboratory animals (Patel,

2000). Cathinone enhances and speeds up the responses in laboratory animals (Kalix &

Khan, 1984). There is a disagreement about whether the Khat can cause dependency like

amphetamines. Many scholars suggest that khat has psychological dependence rather

than physical dependency. Tolerance of Khat does not happen, and if it does, doses are

increased slowly. The cause of this may be because of the inherent properties of the Khat

and the limitation of the consumable amount as natural form (Lamina, 2010). There are

many controversies to whether there is withdrawal syndrome from the substance abuse,

but many physical withdrawal symptoms have been shown, like depression,

28

Hypersomnia, anergia, marked trembling and low blood pressure are seen after

withdrawal of the substance. The study showed that only 0.6% of the Khat consumers

continue to chew just to prevent withdrawal symptoms (Lamina, 2010).

Problems Related to Khat Addiction

Khat utilization has been related to various issues. Basic researches about Khat

related problems have discovered evidence of changed stress response, cognitive deficit,

and sleeping related problems. Research has demonstrated as well that long time use of

Khat may prompt to a prolonged sensitization of the effect of the other drugs. Not only

physical and mental harm, but also much time and family income is spent in acquiring

and chewing khat, which immensely influences the consumer’s social life and family

(Odenwald & Al'Absi, 2017).

Physiological problems. Khat creates problems in the digestive system. The

presence of tannins in Khat affects the digestive tract mainly it causes constipation and

gastritis and loss of appetite. The undernourishment and constipation are accredited to

both nonpseudoephedrine and tennins. Khat is also the primary factor in the development

of periodontal and the brownish pigmentation of the teeth. Toxicity has been assessed in

laboratory wildlife; there have been reports citing that Khat extracts contain mutagenic

factors (Al-Motarreb et al., 2010). There is also another report stating that there is a

strong link between Khat uses and oral cancer that may come from the insecticides used

for growing the plant. On the other hand, any extrapolation of such data is problematic.

Khat increases blood pressure and heart rate (Al-Motarreb et al., 2010). A study showed

that there is an increased incidence of cardiovascular disorder like acute myocardial

infarction (AMI) that is linked to chewing Khat. In a country like Yemen which is part of

29

the countries that its people use the Khat, there is a difference in the patterns of (AMI)

symptoms during the day between the substance users and non-users. Non-users show to

present symptoms in early hours of the day, whereas users of the substance tend to show

symptoms in late afternoon and evening which is the time most of the Khat chewing

sessions (Al-Motarreb, Al-Kebsi, Al-Adhi, & Broadley, 2002).

Khat has an adverse effect on the normal functions of the urinary system. The

level of kidney function tests biomarkers: creatinine and blood urea nitrogen (BUN)

concentration were higher in the test groups (treated with Khat extract) as compared to

the negative control (administered with rodent pellet and water only) which indicated that

the extract of Khat hurt the renal cells and tissues. Khat causes the relaxation of the

urinary bladder wall and closes the internal sphincter. There is a possibility of urine

retention and a reduction in the urinary flow rate (Gitonga et al., 2017). Khat ingesting is

also known to cause spermatorrhea, and prolonged use may lead to spermatozoa, and in

the advanced phase of loss of libido, this result in a new study on rabbits was established

to be related to large dose. Cathinone matters in this plant may be partly or entirely

accountable for the multiplicative toxicity in human and in investigational faunas. This

effect seems to be a reduction in semen production; sperm total, motility and an upturn of

atypical sperms. It has been brought into being that Khat reduces fertility through this

mechanism, which is changeable by the departure of its usage (Gashawa & Getachew,

2015).

Khat is also said to have a significant impact on the pregnant mother by

decreasing maternal daily food consumption which in turn decreases the birth weight of

the infant. Low birth weight is a causative risk factor for both prenatal and child

30

mortalities amongst Khat chewers throughout pregnancy. It can have an impact on fetal

growth during gestation through placental inadequacy, which could be clarified by the

high blood pressure recorded among these women. In much experimentation, visceral and

skeletal deformities have been stated but have not been demonstrated yet in humans

(Dhaifalah & Santavy, 2004; Nakajima et al., 2017).

Psychological problems. Khat chewers can be believed to demonstrate a scope of

mental health problems, from minor issues to the development of major illnesses such as

psychosis. Minor responses incorporate over-talkativeness, hypersensitivity, sleeping

difficulties, aggression, and anxiety. The major psychiatric signs identified with the

utilization of Khat are depression, mania, psychotic symptoms, and brief schizophrenia.

On occasion, these symptoms are connected with occurrences of either self-harm or harm

to other people. Unlike amphetamines, the amount of psychoactive substance in Khat is

less because of the route of administration and the natural form of Khat. In this manner

psychosis as a result of excessive use is significantly less occurring with Khat than that

with amphetamines. Intoxication with Khat is additionally self-limiting, yet the presence

of behavioral disorder and worsening of mental process as a result of chronic use of Khat

contributes the deficiency of mental wellbeing (Basker, 2013; Magdum, 2011).

Odenwald et al. (2009) found that paranoia was most frequent on the individual who

excessively abuse Khat. Furthermore, Khat was mostly used by respondents with PTSD

who demonstrated that they discovered Khat assist them with forgetting war encounters.

The data supported that hypothesis that chewing Khat mediated PTSD to cause paranoia.

Khat chewing also contributes the preexisting psychotic disorder as it confirmed

by many types of research (Bimerew, Sonn, & Kortenbout, 2007; Odenwald et al., 2005;

31

Odenwald et al., 2012; Teferra, Hanlon, Alem, Jacobsson, & Shibre, 2011). In any case,

the exacerbation of psychotic symptoms depends on the way to use Khat such as more

hours of Khat chewing, daily use, night time use, and a high quantity of Khat use. More

to that few researchers have addressed the inquiry that chewing Khat can initiate the

development of chronic psychotic disorders (Kroll, Yusuf, & Fujiwara, 2011; Odenwald

et al., 2005; Tulloch, Frayn, Craig, & Nicholson, 2012). An ongoing report was done in

Ethiopia found that, in the general male population of an African nation; the effect of a

substance can be increased by a traumatic experience. This is in accordance with

behavioral sensitization paradigm, which proposes that chronic experience of stress or

amphetamines use can increase the dopamine release which intern facilitates the

development of the symptoms of psychosis (Adorjan et al., 2017).

Nakajima et al. (2017) found that those individuals who depend on Khat had

increased the adverse effect and sleep disturbances. This was in line with reports of

enhanced distress and emotional reactivity of khat users seen in a laboratory stress

environment as well as reports of verbal aggression and disruptive behavior in some

chronic khat users. Khat chewers experience a negative emotional state beginning 2 hours

or so after the onset of a khat chewing session, a state that can last for several hours. It

has been hypothesized that frequent khat chewers may experience multiple episodes of

negative effect within and between khat chewing episodes, thereby increasing the

likelihood of more persistent negative emotional states (Bongard, al’Absi, Khalil, & Al

Habori, 2011). Hassan, Gunaid, El-Khally, and Murray-Lyon, (2002) demonstrated that

there is a significant state of mood changes towards depression and anxiety amid using

32

Khat. The aftermath of Khat conception is reported to be anxiety, reactive depression,

and irritability.

Some basic researches have confirmed the effect of Khat on changing the stress

response (Al'Absi et al., 2013) and a sleeping disorder (Nakajima et al., 2014) and

cognitive deficits (Hoffman & al'Absi, 2013) in routine khat users. Khat also affects the

cognitive flexibility as it is showed that Khat users increase switching cost for

recreational use. Likewise, the is different for working memory updating for the Khat

users and non-Khat users, and these deficits are linked to the effect of the longtime use of

cathinone on reducing the function of prefrontal cortex and dopamine level in the

striatum (Colzato et al., 2011)

Social and financial problems. In societies where the usage of Khat is regular, it

has a harmful impact on their social and economic situations. Khat consumption leads to

wasted work hours reduced economic productivity, malnutrition and spending too much

money on Khat. This is indirectly related to unemployment and absenteeism, which as a

result can cause the economic drop in overall national economy and production. Reports

are stating that chewing Khat habitually has led the reduction of production in Somalia,

Uganda, Ethiopia, and Kenya (Aden, Dimba, Ndola, & Chindia, 2006; Ageely, 2008;

Eticha, Kahsay, Ali, & Janapati, 2016). Though it is mentioned that reasonable use of the

substance increases the production as it improves the activity by keeping starvation and

exhaustion at bay, however, in the countries like Somalia, Kenya, and Ethiopia low

production was linked to Khat. Furthermore, it is predictable that one-third of all salaries

were paid out on Khat. Many men were said to use a large part of the family income on

Khat at the expense of vital needs. Family life is affected as a result of negligence; the

33

indulgence of household wages, therefore, a chief factor in family arguments, in fact, one

out of two divorces were said to be caused by Khat abuse (Basker, 2013; Magdum,

2011). Khat is cited as a factor in one of two separations in Djibouti. Getting hold of

funds to pay for Khat may be the chief cause of the illegal behavior and even prostitution

(Elmi,1983). The poor people in the cities are the most affected, but in rural areas, the

effect is that their small fertile land and water are used for cultivation of Khat instead of

food and crops (Magdum, 2011).

Khat is said to be the main factor in the arguments between married couples and

family conflicts in general if they have a user of Khat. Those disagreements are said to

come in different forms in which two are the main: aggression from the husband side

particularly after consuming Khat and as a consequence of quarrels neighboring the

economic repercussion of Khat use. Commonly anger flares up when the user comes

home late at night and denies explaining his extended absenteeism from home, therefore,

causes a rift in the spouses’ relationship. The foiling of the substance used as a product of

the sleeplessness, combined with the strains that resulted from the conflicts of the coming

late of the last night, leads to hostilities on the side of the user. As one can visualize, with

the continued pressure between the twosomes, the agreement in the family might be

affected dysfunctions in the family (Jibril & Yusuf, 2012).

This is another way in which encounters are formed. Differences in the quantity

of cash that are to be spent on Khat by the substance user are frequently central to the

clash. The Somali`s family structure which is extended family, additionally worsens the

present problem among the married couples. The notion that, even though the women are

married to a man still she is the sister and the daughter of someone, that leads mostly to

34

the intervention of relatives if the husband mistreats his spouse. Commonly, women share

their problems and crisis with their close blood relatives, which on the other hand discuss

the problem with the Khat using husband. In most circumstances, this brings

impediments like divorce (Jibril & Yusuf, 2012).

Khat affects young people in diverse ways. It is clear that the effects of Khat on

relations and the consumers themselves might have negative influences on the young

people’s lives. One of the most recurring effects of a substance on kids is a

misunderstanding with their fathers, i.e., where broods often come across ‘edgy dads’

with recurrent ‘mood-swings,’ as transmitted by a female research member. ‘Mood-

swings’ suggested the ‘frequent’ intermitted instants of ‘bad temper and happiness’

which is the main reason kids are confused. Young people often have problems with the

characters and ‘predictability’ of their substance user fathers and disordered meanwhile

they do not know what to expect from him.’ Furthermore, by being busy with substance,

those fathers had a short time for their kids. They exhibit carelessness toward their

children because they spend most of their time in finding and chewing the substance.

Furthermore, youngsters were frequently unprotected to the encounters that followed as a

result of familial encounters that stemmed from the substance abuse of their dads.

Psychologically, such clashes involved immense suffering and timidity on the part of the

youngsters. These young people also feel abandoned in that their dads pay slight care to

their requirements, both substantially and psychologically (Basker, 2013).

Moreover, there have been some anti-social behaviors in which an individual who

is chewer may engage in during and after chewing khat. Chewers usually drive cars that

are used to deliver khat from one town to another, and it is usual to see those cars

35

speeding up to limits that are dangerous for the public. Another problematic source for

the general population is the overcrowding and large noises of the markets used to sell

Khat. Additionally, the leaves of the tree (Khat) are usually the parts that are chewed, but

the chewers throw away the stems in the streets, and that adds to the general public health

issue of waste accumulation in the community. Another point is that since Khat is costly

and most of the chewers are unemployed, they engage in acts of anti-social behaviors

such as stealing, and theft. Similarly, regular use of Khat caused sleeplessness that creates

irritability and agitation and irregularity at workplaces that made many Somalis jobless.

Regular Khat use is also associated with an increase in physical and verbal aggression, as

well as violence in general. It is caused by lack of sleep, frequent agitation and mood

swing that increase the likelihood of the individual to have interpersonal problems.

Besides, constantly asking others for money, stealing, and sometimes robbery can

increase the likelihood of having interpersonal problems. Moreover, Khat chewers, spend

much time consuming it, which makes a barrier for the individual to have the reasonable

time spent in social interactions (Hunter et al., 2012; Warfa et al., 2007).

Risk Factors of Addiction

Biological model. Many theories have been developed for understanding the

causes and the mechanism of substance use, and addiction in general. Each of these

theories focused on some aspects of the phenomena (West & Brown, 2013). Some of

them focused on the genetic and the neurochemical that underlie drug reliance. These can

be gathered into two sorts of clarifications; one which inspects singular contrasts in risk

to drug reliance as a result of hereditary qualities, and one which represents drug reliance

as far as changes that happen in the mind because of repetition of the drug. One theory

36

concerning drug reliance is that individuals may acquire genetic susceptibility of

developing drug dependency. The subject of whether such susceptibility exists has been

analyzed in various family studies, adoption studies, and twins. Family investigations of

substance use issue recommend that such issue do run in families. appropriation studies

look at paces of disease among adoptees, given their blood and new parents' issue status.

These studies found some significant for adoptees to use the substance if their biological

parents were using. Research recommends that there is a noteworthy hereditary factor

that impacts adoptees' susceptibility to liquor use disorders (Berridge, 2017; Herrnstein &

Prelec, 1992; West & Brown, 2013).

The other explanation of addiction depends on the idea of neuroadaptation.

Neuroadaptation alludes to changes in the brain that jump out at restrict drug intense

activities after frequent use (Nutt, Lingford-Hughes, Erritzoe, & Stokes, 2015). This

might be of two kinds: inside framework adjustments, where the progressions happen at

the site of the medication's activity, and between-framework adjustments, which are

changes in various components that are activated by the medication's activity. When

medications are frequent, changes happen in the structure of the mind to depend on the

drug. At the point when this drug use is ended, the adjustments are never again restored

and the brain's homeostasis is changed. Basically, this theory contends that resistance

with the impacts of a medication and withdrawal when medication use stops are both the

aftereffect of neuroadaptation. Creature models have demonstrated that unpleasant boosts

enact the dopamine remunerate framework, so susceptibility to backslide from

forbearance is estimated to happen. Therefore, substance use proceeds trying to maintain

a strategic distance from the side effects that pursue if drug use stops (Berridge, 2017).

37

While, customarily, conceptualizations of drug reliance concentrated on physical

withdrawal side effects, later details have started to focus on the nearness of increasingly

inspirational manifestations, for example, dysphoria, sorrow, irritability, and tension. It

has been conjectured that these negative inspirational side effects are indications of

neurobiological changes, and that these progressions signal not just the start of the

development of reliance, however may likewise add to susceptibility to backslide and

may likewise have persuasive importance. This methodology speculates that, after

constant medication use, changes happen in the dopamine compensate framework and the

endogenous opioid framework (Koob et al., 1997).

Contextual factors. There is a lot of proof to recommend that individuals with

antisocial tendency are bound to develop substance abuse. Teenagers with conduct

disorder is believed to be more likely to have substance use problems than others without

conduct disorder (Cicchetti and Rogosch, 1999). By and large, apparently the prior,

progressively differed and increasingly genuine a youngster’s antisocial behavior, the

almost certain will it be proceeded into adulthood, with substance abuse considered as

one of these standoffish practices. Besides, kids or youngsters with anxiety and

depression are bound to start substance use at an earlier age (Cicchetti and Rogosch,

1999).

Peer pressure likewise has a large impact on individual to use drugs. Substance

use for the most part starts with friends, and the attitude of peers toward the drug have

profoundly shown to be the most predictable of teenage substance use, and it is because

38

they spend more time with friends who use drugs. There is, in any case, no proof

concerning the impact of friends on the development of dependence of drug (Loeber,

Southamer-Lober, &White, 1999). The likelihood to use substance is also linked to

families in many ways including modeling, permissive attitude, problematic relationship

between members of the family, and so on (Hawkins, Catalano, & Miller, 1992). Other

sociocultural factors that linked to addiction are lower socioeconomic backgrounds, less

education, school dropout, and grown up in an area of high crime or more available of the

drug (Hawkins, Catalano, & Miller, 1992).

Psychological factors. Psychological ways to deal with the explanations of the

cause and maintenance of substance abuse have regularly been founded on the concept

that are similar to other disorders linking to the symptoms like impulsivity, compulsion,

and so on. Specifically, the focus of psychological explanation is around lack of control

to the use of the substance and the consumption despite the harm that is associated with

the substance. There are numbers of psychological ways to explain the phenomena of

drug dependence such as behavioral theories and personality theories (Lindesmith, 2017).

Behaviorist models of substance abuse has concentrated the substance use behavior that

is observable. One explanation focuses on the way that substance use behavior is kept up

(or made more probable) is by the reinforcers that results the use of the substance. This

led the perception that prompted the development the use of substance as self-

administration. The use of substance according to this model is reinforced by stimulation

of the drug in reinforcement center of the brain, or giving social or material gain (West,

1989). Another explanation of drug dependence that based on behaviorist model is the

classical conditioning which believe after the drug is associated with other needed things,

39

then the person develops same need for the drug. Graving and cue explanation theories

are more based on classical conditioning (Heather & Greeley, 1990).

Personality traits. Personality characteristics consist of a range of individual

differences in the way of thinking, feeling, and behaving. These attributes are generally

depicted regarding higher-order traits that subsume smaller lower traits. Personality

differences have been associated with wellbeing as it is being related with practices that

can influence health outcome, including social connections, exercise, dietary patterns,

and substance use (Caspi et al., 2005). Various etiological structures for substance

utilizations found that personality traits are linked to individuals’ differences on the

susceptibility of substance abuse (Conway, Swendsen, Rounsaville, & Merikangas, 2002;

Grekin, Sher, & Wood, 2006; McGue, Slutske, & Iacono, 1999; Sher, Bartholow, &

Wood, 2000).

Various investigations have found evidence for cross-sectional and longitudinal

connections between personality traits and substance use (Bernhardt et al., 2017;

Darharaj, Habibi, Kelly, Edalatmehr, & Kazemitabar, 2017; Del Pino-Gutiérrez et al.,

2017; Foulds, Boden, Newton‐Howes, Mulder, & Horwood, 2017). For example, the

five-factor model of personality is an experimentally upheld classification containing the

attributes of extraversion, neuroticism, conscientiousness, agreeableness, and openness to

experience. Low conscientiousness, low agreeableness, and high neuroticism have been

related to higher rates of alcohol consumption (Malouff, Thorsteinsson, Rooke, &

Schutte, 2007). Also, a cross-sectional investigation of early adulthood, associated with

higher neuroticism and lower conscientiousness with non-prescribed anxiolytic and

narcotics use (Benotsch, Jeffers, Snipes, Martin, & Koester, 2013).

40

Cloninger (1987 a, b) proposed a typology of alcohol abuse that ordered heavy

drinkers into two groups given a period of the beginning of alcohol consumption and

other comorbid conditions. Type I alcohol abuse was portrayed by a late time of

beginning and inclination to depression and anxiety, whereas, type II alcoholism had a

tendency to have an early beginning and was connected to impulsivity and antisociality.

These groupings were separated as far as three aspects of personality: novelty seeking,

harm avoidance, and reward dependence. Type I alcohol abuse was related with bringing

lower novelty seeking, higher harm avoidance, and higher reward dependence, while type

II is linked with higher novelty seeking, lower harm avoidance, and lower reward

dependence. Similarly, the process of alcohol usage additionally differed between the two

groups. Utilization of alcohol to adapt to negative life situation was more related to Type

I, while Type II was identified with the utilization of alcohol for its stimulating or

improving effects.

Expanding the Cloninger's work, later examinations of individual differences in

the advancement of substance use problems have shown connections between particular

personality aspects and desire for substance abuse. This study has updated the

development of a motivational theory suggesting that different personality characteristics

are connected to susceptibilities for using substances. With this framework, Conrod and

his colleagues built up a system classifying substance abuse individuals on the bases of

four personality dimensions: anxiety sensitivity (AS), hopelessness (H), sensation

seeking (SS), and impulsivity (IMP). Anxiety sensitivity depicts a tendency to expect that

nervousness, especially when physiological arousal accompanies it, will prompt social

embarrassment, illness, or loss of control. Hopelessness depicts an inclination towards a

41

pessimistic outlook about the future that results in sadness. Sensation Seeking portrays a

penchant for searching out exciting experience that includes the use of substances with

euphoric subjective quality. Impulsivity depicts a pattern of behavioral disinhibition

combined with trouble in reckoning the long-term adverse outcomes of one's behavior.

This conceptualization considers personality characteristics as moderately stable that go

about as risk factors for substance abuse (Conrod, Pihl, Stewart, & Dongier, 2000).

The well-studied model of personality traits that are related to addiction is

Eysenck’s (1990) personality theory. The theory centers around the three higher-order

aspects of personality, Extraversion, Neuroticism, and Psychoticism that have been used

for the comprehension of substance use, with high neuroticism and psychoticism scores

being especially implicated in alcohol and drug abuse. While personality traits have been

depicted as "distal" to substance abuse, evidence shows that personality can separate

substance users in light of their thought processes in the utilization of different substances

(Sher et al., 2000).

Some other studies have found the relationship between the three Eysenck

personality traits and addiction. Gossop (1978) attempted to research the personality

variation amongst oral and intravenous drug addicts. He revealed that the two group

scored high on the neuroticism and psychoticism, however, oral user demonstrated a

significantly higher score on both dimensions than another group. Gossop and Eysenck

(1980) attempted to look at the personality of 221 addicts at three London treatment

centers and 310 normal subjects. The two groups were filled the Eysenck Personality

Questionnaire. They found a difference for the most of the items between the two groups.

Gossop and Eysenck (1983) broadened their past study and took the personality of

42

substance abuse and detainees by using the Eysenck Personality Inventory. They

uncovered that addicts scored higher on the Psychoticism and Neuroticism subscale,

while Prisoners altogether scored higher than addicts on the Lie scale and Extraversion.

Abu-Arab and Hashem (1995) selected three male groups (involuntary in-patients,

volunteer in-patients, and volunteer outpatients) which consisted of 50 participants each

to investigate the personality traits of drug addicts by administering the Eysenck

Personality Questionnaire (EPQ). As per the finding of the investigation, the IIP group

scored higher than the VIP and VOP on the Neuroticism, Psychoticism, and the Lie scale.

On the Extraversion scale, the IIP altogether scored higher than the VOP. The VIP and

the VOP just differed on the Neuroticism scale. Spielberger and Jacobs (1982) examined

the association between personality attributes and the habit of smoking. They picked nine

hundred and fifty-five students and were asked them to fill a protocol that consists on

Smoking Behavior Questionnaire, Eysenck Personality Questionnaire (EPQ), and the

State-Trait Personality Inventory (STPI). They found that smokers had significantly

higher scores than non-smokers on the dimensions of Neuroticism, Psychoticism, and

Extroversion, while scored low on the Lie Scale. They moreover surmised that

personality traits affect the beginning and keeping up of smoking behavior.

Blaszczynski, Buhrich, and McConaghy, (1985) estimated that like other drug

addicts the pathological gambling can be labeled as an addictive disorder. To demonstrate

that they replicated the Gossop and Eysenck (1983) finding that the scales of EPQ

isolated drug addict from controls. They picked 60 pathological gamblers, 51 heroin

addicts, and 52 controls, and they administered 32 items of Addiction Scale drove from

the Eysenck Personality Questionnaire (EPQ). Their result bolstered the initial

43

hypothesis. The controls scored lower on Addiction, Neuroticism, and Psychoticism

Scales than other two groups.

Model Adapted in this Research

For sure, there have been various ways to deal with clarify why some people

become subject to psychoactive substances. Each approach hereditary, psychological, or

sociocultural no doubt many researches has been supported. However, none of these

approaches explain the addiction comprehensively and there is dying need to have

integrated model for explaining all dimensions of addiction. Right now, the

biopsychosocial model is the bases of most addiction treatment approaches and is the

only form of explanation that takes into account all angels of the phenomina. As opposed

to the disease model, the biopsychosocial model sees "dependence" as a mind boggling

standard of conduct having biology, mental, sociological, and believe parts. So that in

this research personality traits are considered as risk factors of Khat addiction and the

mechanism is assumed same as the other addictions. Similarly, interpersonal difficulties

and mental health problems are regarded as both the risk factors of Khat addiction as

indicated by self-medication hypothesis (Khantzian, 1997) and consequences of Khat

addiction as indicated by toxicity hypothesis (Colizzi & Murray, 2018).

Treatment of Addiction

Substance abuse is entirely recoverable condition and highly possibility of full

remission. Since progress tends not to happen at the same time, any progress is viewed as

significant indications of progress. Time after time, new model of dealing drug

dependence is developing such as Community Reinforcement Approach (CRA) (Azrin

44

1976; Meyers and Smith 1995), Beck's Cognitive Therapy (Beck et al. 1991), Marlatt's

Relapse Prevention (Marlatt and Gordon 1985), twelve stages, relational psychotherapy.

Cognitive therapy is an arrangement of psychotherapy that endeavors to lessen

over the top emotional responses and self-defeating behavior by adjusting the fault

thingking and beliefs that underlie these responses. The Community Reinforcement

Approach (CRA) "is a wide range conduct treatment approach for substance misuse

issues that uses social, recreational, familial, and professional reinforcers to help

customers in the recuperation procedure. Motivational Enhancement Therapy (MET)

(Miller and Rollnick 1992). MET "depends on standards of persuasive brain research and

is intended to create quick, inside spurred change. This treatment technique doesn't

endeavor to guide and prepare the client, bit by bit, through recuperation, however rather

utilizes persuasive systems to assemble the client's very own change assets. Twelve-Step

is grounded in the idea of substance as a profound and medicinal illness. Notwithstanding

restraint from every single psychoactive substance, a significant objective of the

treatment is to encourage the member's promise to and cooperation in self-help meetings.

Interpersonal Psychotherapy (IPT) (Rounsaville and Carroll 1993) depends on the idea

that numerous mental issue, including drug reliance, are personally identified with

clutters in difficult of interpersonal relationships. All these therapies are either missing

important components or addiction such as behavior for cognitive therapy, or cognition

for CRA. Also, some of them are not cost effective and continue for long duration.

However, cognitive behavior therapy (CBT) is promising by fulfilling some of the

limitation of other model of addiction therapy.

45

Cogntivie behavior therapy. A cognitive model of therapy was developed by

Beck (1967, 1976) which says the important thing is the meaning individuals give to their

experience, not the experiences itself. Further, it was added to behavioral therapy and

then named Cognitive-behavior therapy (CBT) that became one of the leading

psychological therapies for mental health problems. As the name infers, CBT was

established in both cognitive and behavior therapies; however, it is not just a combination

of behavior and cognitive techniques. CBT has been and will be the subject of

examinations and extensive evaluations. Early cognitive behavioral therapies for panic

disorder and depression have clinical support and have been additionally upheld by

outcome studies as well. Initially, the focus was to separate the therapy from previous

therapies (i.e., psychoanalytic), by finding the unique characteristics of the new model.

At a later stage, the research was focused on testing the validity of the concepts the

causes and recovery of mental health problems (Craske, 2010).

All cognitive behavior therapies share similar characteristics: they all are

collaborative, brief, focused, and structured. Both client and therapist are imperative and

need to share and concede to the points of the treatment. Treatment is not something that

is imposed on the individual; instead, the client is effectively engaged in the treatment

procedure. The client’s perception and interpretations are as imperative as therapist's,

with the therapist being directive in helping the client to think about alternative

explanations of any situations. It is also crucial to practice the agreed on activities to

increase the treatment outcome. The structure is fundamental to keep the end goal in

mind, to be collaborative and focus on the client’s present problems. However, the

structure does not mean to be inflexible, and there is always space for an update and a

46

change of the course. Both client and therapist are in charge of setting and following the

structure of the treatment (Craske, 2010).

Most CBT models offer a limited number of sessions, which are generally based

on the theory and the clinical experience of the therapist. However, pervasive disorders

such as personality disorders and eating disorders can take more sessions than other

disorders. The therapy is focused on the here and now, although it acknowledges the

early experiences are essential for the development of schemas, yet the aim of the therapy

is not to deal with deep-rooted and stable structures. Similarly, as with other mental

health problem, several CBT models that deal with addiction have been established.

While they do not give attention to the very same components of the procedure of the

psychotherapy, yet they overlap, and sometimes they use the same concepts with

different words. Having said that, the most familiar addiction model is Marlatt’s model

for relapse prevention (Marlatt and Gordon, 1985). Grounded in the theory of social

learning by Bandura, it was designed for the prevention of alcohol consumption of

individuals in treatment residential (Bandura, 1977). The model was also successfully

implemented in drug addictions like opioids, cigarettes, and stimulants.

Efficacy of CBT for drug addiction. The use of cognitive behavior therapy

(CBT) for the treatment of substance abuse is effective when used as a single treatment

and when used with other therapies as well (Dutra et al., 2008; Magill & Ray, 2009;

Vidrine, Cofta-Woerpel, Daza, Wright, & Wetter, 2006). Even though CBT for substance

abuse is depicted by different treatment constituents, for instance, developing skills,

cognitive and motivational aspects, and operant learning techniques, yet some strategies

47

emerge that deal with reinforcing aspects of the substances. CBT for substance abuse can

also be run individually or as a group (McHugh et al., 2010).

The underlying assumption of CBT is that learning processes play an important

role in the development and continuation of substance abuse and dependence. These

same learning processes can be used to help individuals reduce their drug use (Dutra et

al., 2008; Magill & Ray, 2009) Several important features of CBT make it particularly

promising as a treatment for substance abuse and dependence: CBT is a short-term,

comparatively brief approach well suited to the resource capabilities of most clinical

programs. CBT is structured, goal-oriented, and focused on the immediate problems

faced by substance abusers entering treatment who are struggling to control their use of

the substances. CBT is a flexible, individualized approach that can be adapted to a wide

range of patients as well as a variety of settings (inpatient, outpatient) and formats (group,

individual). CBT is also compatible with a range of other treatments the patient may

receive, such as pharmacotherapy. CBT’s broad approach encompasses several important

common tasks of successful substance abuse treatment (Vidrine, Cofta-Woerpel, Daza,

Wright, & Wetter, 2006).

The key active ingredients that distinguish CBT from other therapies and that

must be delivered for adequate exposure to CBT include the following: Functional

analyses of substance abuse, individualized training in recognizing and coping with

craving, man aging thoughts about substance use, problem solving, planning for

emergencies, recognizing seemingly irrelevant decisions, and refusal skills. Also

examining the client’s cognitive processes related to substance use, and Identification of

48

past and future high-risk situations. Practicing the skills learned during the sessions in on

the field outside the therapeutic situation (Dutra et al., 2008).

Countless trials and quantitative reviews back the success of CBT in the

management of substance-related problems. For example, a meta-analytic review of CBT

for substance abuse containing 34 randomized controlled trials (RCT), with 2340 patients

treated, showed a practical effect of CBT on substance abuse (Dutra et al., 2008). The

most noticeable effect was on the cannabis treatment, followed by the cocaine and

opioids treatment with the least effect seen on poly-substance addiction. On the

individual level therapies, contingency management of relapse prevention had the best

impact (Dutra et al., 2008). This was reinforced as well by Meta-analytic review of CBT

trials by Magill and Ray (2009) which revealed a comparable outcome. In addition,

evidence shows the overtime power of the therapy (Carroll et al., 1994). For instance, a

study of the psychosocial treatment for cocaine dependence, Rawson et al. (2006)

discovered that 60% of patients that underwent CBT had clear toxicology result 52 weeks

later.

Behavior and cognitive therapies are the bivariate psychological treatment for

substance abuse. Their efficacies are validated, and at the present CBT is the fundamental

treatment approach to alcohol, stimulant and cannabis addiction (Kouimtsidis, Davis,

Reynolds, Drummond, & Tarrier, 2007). The tenet of CBT in addiction is that addictive

behavior is learned by repeating overtime and it is subjected to unlearning it. Cognitive

therapy primarily intends to change addictive behavior through changes in distorted

believes that serve to keep up the behavior (Beck, Wright, Newman, & Liese, 1993)

whereas, behavioral therapies principally expect to alter practices supported by adapted

49

learning: classical and operant conditioning. Behavioral approaches that use aversive

molding have evidence for the most part in the alcohol treatment, however, are not

utilized primarily for ethical reasons.

Psychological approaches that integrate cognitive and behavioral strategies have

shown compelling evidence of reducing dependency and maintaining abstinence from

most types of substance abuse in various investigations, either monotherapy or in

conjunction with pharmacological interventions. The therapies that aimed to deal the

addictive behavior mostly used the term psychosocial interventions which is either CBT

or motivational interviewing (MI), treatments which are evidence-based and have clear

basic principles (Wanigaratne, Davis, Pryce, & Brotchie, 2005).

Rationale

In 1991 the Somali central government collapsed and was followed by war,

conflicts and instability in the country that led to the displacement of many Somalis. As a

result, the opportunities for education and employment became limited; a lot of free and

unstructured time without constructive and challenging social alternatives increased; and

a widespread availability of Khat because of the elimination of government restrictions.

Moreover, in order to escape frustration caused by war and unemployment many

individuals started chewing Khat. Since then, not only has the percentage of population

who chew Khat increased, but also the amount of Khat, frequency, and length of the

sessions of Khat increased. The attitude towards Khat changed as well, and Khat chewing

became more acceptable in society, especially for males (Hansen, 2010).

As the chewing Khat became augmented, so did the problems related to the usage

of Khat. World Health Organization (WHO, 2010) found that one of each three Somalis

50

has some form of mental health issue, and besides, the conflict and instability in the

country, chewing Khat is one of the causes of the rising mental health problems in the

country. Moreover, Khat creates physiological problems, social issues, and financial

difficulties for both individual and country in general. In order to control a problem, it is

important to first understand it, and because Somalia was unstable for decades, there are

few studies that take place on chewing Khat in Somalia (Odenwald et al., 2007). Most of

the studies that related to chewing Khat were taking place on Somalis who are

immigrants in Europe, USA, Australia, or refuges in neighboring countries of Somalia.

For that reason, it is needed to conduct many researches related to using Khat in a Somali

context.

Therefore, the present studies intended to fill some of these gaps and chose only

male undergraduate university students as participants. Only male students were chosen

because of their relatively high probability in consuming Khat in contrast to females, as

well as being categorized under ‘university’ students, out of those limited female khat

consuming population. Moreover, the female students were not included in the

participants as stigma is associated with the female that chews Khat in Somalia, and they

hide their habit which make difficult to find them (Kassim, Dalsania, Nordgren, Klein, &

Hulbert, 2015). University students were selected for the study since they can easily

comprehend the language of the scales which is English and are convenient to participate

in the study. There were four studies that were conducted and the first was to develop

Khat Interpersonal Difficulties Scale (KIDS), because there was no scale for

interpersonal difficulties related to Khat or addiction in general. Subsequently, the

prevalence of Khat chewing among undergraduate university students was determined,

51

because the last prevalence rate of chewing Khat in Somalia was 1983, and one of the

bases of controlling phenomena is to know how wide it is. A cross-sectional study was

also carried out to disclose the difference between those who use khat and those who

don’t use Khat as the bases of personality traits, interpersonal difficulties, and mental

health problems.

Finally, an experiment was conducted to find out the effectiveness of cognitive

behavior therapy on using Khat. Cognitive behavioral therapy (CBT) for substance use

disorders has demonstrated efficacy as both a mono-therapy and as part of combination

treatment strategies (McHugh et al., 2010). Despite heterogeneity of habit of substance

abuse, core elements are characterized by learning processes and driven by the strongly

reinforcing effects of substances of abuse. CBT for substance abuse captures a broad

range of behavioral treatments including those targeting operant learning processes,

motivational barriers to improvement, and traditional variety of other cognitive-

behavioral interventions (McHugh et al., 2010).

Research Questions and Hypotheses

Research question one

What is the prevalence rate of using Khat among Somali university students?

Research question two

What are the differences in personality traits, interpersonal difficulties and mental

health problems of the students who chew Khat and those who don’t?

Main hypotheses

52

1. It is hypothesized that those students who chew Khat would experience more

interpersonal difficulties and mental health problems as compared to those

students who don’t chew Khat.

2. It is hypothesized that there would be difference on personality traits between

students who chew Khat and those who don’t.

Secondary hypotheses

3. It is hypothesized that those students who scored high on neuroticism,

psychoticism, use Khat more hours a day, and chew Daba Musbar (the strongest

type of Khat in the region) would have more interpersonal difficulties.

4. It is hypothesized that those students who scored high on extroversion,

neuroticism, psychoticism, and chew Daba Musbar (the strongest type of Khat in

the region) would experience more mental health problems.

5. It is hypothesized that experiencing interpersonal difficulties is partially or fully

mediate the relationship between personality traits (Neuroticism and

Psychoticism) and mental health problems.

6. It is hypothesized that the more frequent the individual uses Khat the more the

individual have Psychoticism and Neuroticism personality traits, and experience

interpersonal difficulties and mental health problems.

7. It is hypothesized that the longer the person chew Khat the more the person

becomes introverted.

8. It is hypothesized that those students who use Khat alone would have experience

more interpersonal difficulties and mental health problems as compared to those

students who use Khat in-group.

53

Research question three

How much effective is the cognitive behavior therapy for significantly reducing

Khat addiction and related problems in Somali university students?

Main hypothesis

9. It is hypothesized that those university students who attend seven sessions of

manualized cognitive behavior therapy would experience a significant decrease of

Khat Addiction and related problems as compared to those who receive psycho-

education only.

Secondary hypothesis

10. It is hypothesized that those Khat user students who receive 7 sessions of CBT

would significantly reduce Khat chewing behaviors as compare to those Khat user

students who receive PET.

54

Chapter III

Method

The method section consisted of four parts. The first part discussed the steps that

were used to develop the Khat Interpersonal Difficulties Scale (KIDS), and the second

part deals with finding the prevalence of chewing Khat among university students. The

third part, which is the main study, focused on the exploration of the differences between

Khat users and non-Khat users based on personality traits, interpersonal difficulties, and

mental health problems. The final part examined the efficacy of cognitive behavior

therapy on the habits of chewing Khat and its related problems.

Settings

The study was conducted in the semi-autonomous northern region of Somalia

(Somaliland). Roughly Somalia is divided into two parts, a British protectorate of the

North and Italian colony of South. The two parts united in 1960 and formed the current

state of Somalia. After the civil war erupted in 1991, the two parts were separated again

with the northern side of the country forming a separate government while the southern

side was unstable for a while. Later the southern region became stable, and there is an

internationally recognized government today for all Somalia, yet northern side claims to

be independent. The impact of colonization together with the experience of the civil war

created different social structure and system of government for the two regions of

Somalia. Furthermore, different types of Khat are imported to these two parts that mainly

come from two different countries. In the north of the country Khat is imported from

Ethiopia, whereas in the south of Somalia Khat comes from Kenya. These types of Khat

have a different impact on individuals, as well as on the society. Because of the

differences mentioned above and to avoid confounding, this study focuses only on the

55

northern region of Somalia. The data was collected from university students in the semi-

autonomous northern Somali region called Somaliland.

Study I: Scale Development

This section highlights the development process of the Khat Interpersonal

Difficulties Scale (KIDS) that was created in three phases. The first phase was

phenomenological exploration that intended to gather the items that are related to

interpersonal difficulties on Khat users. In the second phase, a list of interpersonal

difficulties of Khat users that were collected from the first phase and given to 30 khat

users to find out the item difficulties and the use of friendliness of the scale. The final

phase was determining the psychometric properties of the scale.

Research design. The study was carried out by using mixed method design in

which a qualitative phase was conducted for phenomenological explorations of the items

of the developed scale, and quantitative phase for finding the psychometric properties of

the scale. First, in order to construct the scale, open-ended questions were used for

phenomenological exploration related to interpersonal difficulties associated with Khat

users and was followed by the empirical validation of the scale. To construct a

measurement is essential in science since it empowers the researchers to get information

about individuals, for a phenomenon that is difficult to get directly (DeVellis, 2003). One

way of finding a scale is to translate an existing scale that was developed from another

culture. However, this method has many limitations. One of these limitations is each

culture has a different way of coding and encoding information when answering items of

a scale. Moreover, the construct contamination can come from two sources, the

perception of the tone in the statement and the styles of the participant’s responses. What

56

may sound polite in one culture may sound discourteous in another. Also, a particular

way of answering items in one culture may look like a common way of responding to

another culture (Arce-Ferrer & Ketterer, 2003). To overcome these limitations, the

development of a culturally relevant scale was necessary to develop in order to measure

the nature and the scope of the interpersonal difficulties associated with Khat users, as it

takes into account the cultural relevance of the user’s background.

Phase I: item generation.

Participants and procedure. The purpose of this phase was to generate items of a

scale from the interpersonal difficulties experienced by Khat users. A total of 30 male

Khat users from university students with the age range of 18-25 were interviewed. Only

those students who use Khat at least once a week was selected through purposive

sampling technique. A semi-structured interview was used by asking an open-ended

question “What kind of interpersonal problems experienced by those who chew Khat?”

On average each interview took about 10 to 15 minutes and was an individual meeting

with each of the participants. Follow up questions was asked to clarify areas of

ambiguity, and a list of 40 items was extracted. Two items were discarded to avoid

repetition. The participants were interviewed in English and the items of the scale were

developed in the same language (English). In the end, 38 items were finalized and

decided to process the other psychometric analysis further. The scale was named Khat

Interpersonal Difficulties Scale (KIDS).

Phase II: try out. In order to assess the user friendliness, conceptual clarity, and

time consumption which respondents take to complete the questionnaire, a try out phase

was carried out. The participants were (N=40) Khat users’ university students, who were

57

requested to fill the questionnaire based on their oral consent. Only those students who

use Khat at least once a week was selected through purposive sampling technique. All the

participants on phase II were different from the participants of phase I. On average it took

8 minutes to complete the scale. Some participants complained about a lack of

understanding of some of the items, hence, clarifying these items was considered.

Overall, the scale was shaped on the basis of the suggestions that were taken from the

participants during the try-out phase.

Phase III: determining psychometric properties. The purpose for this phase

was to find out the psychometric properties of the KIDS.

Participants. A sample of (N=200) was selected from undergraduate university

students who used Khat. The participants were divided into the four levels of

undergraduate by using stratified random sampling, and then the participants of each

stratum were recruited though snowball sampling including 36 (17.8%) from (BS-I), 44

(21.8%) from BS-II, 55 (27.2) BS-III, and 67 (33.2%) from BS-IV. The sample size for

finding psychometric properties of scale was based on the assertion made by Kline

(2013) that indicated the ratio of the sample to be at least 3-1 for the number of items of

the scale to have factor analysis for scale construction. The participants were male Khat

users from Somali university students aged between 18 to 25 years with the mean age of

20.41 (SD = 1.52). It was selected only those students who use Khat at least once a week,

and the participants of this phase were different than those used for other phases.

Measures. Inventory of Interpersonal Problems Short Circumplex (IIP-SC). The

IIP-SC (Barkham et al.,1996) is a 32-items measure with eight subscales reflecting

distinctive relational problems. The IIP-SC contains eight subscales: non-assertive,

58

domineering, socially avoidant, vindictive, cold, exploitable, overly nurturant and

intrusive, with four items each. A four-point Likert scale is used to measure each item.

The IIP-32 subscales have exhibited sufficient internal consistency in outpatient and non-

clinical examples. IIP-SC has good internal reliability (0.88) and solid test-retest

correlation (0.83) (Soldz, Budman, Demby, & Merry, 1995). Individual subscales

comparatively had sufficient internal reliability: domineering, (0.72); vindictive, (0.69);

cold, (0.77); socially avoidant, (0.80); non-assertive, (0.82); exploitable, (0.70); overly

nurturant, (0.78); and intrusive, (0.83). (see appendix H).

Procedure. The data was collected from the University of Hargeisa and Gollis

that are situated in Hargeisa, the second largest city in Somalia. The Institutional Ethical

Committee approved all study procedure. The study was conducted fulfilling all ethical

considerations at every step. All participants were ensured about the confidentiality,

anonymity and the right to withdraw from the current research. Also, the students were

told the purpose of the study and how the finding will be used. All participants were

given a protocol that comprised of demographic information (see appendix A), KIDS (see

appendix F), and IIP-S (see appendix I). On average 15-20 minutes were taken to finish

the test. For the purpose of find test-retest reliability, around 20% of the participants

agreed to a retest after two weeks. For data analysis, SPSS version 21 was used. The

psychometric properties were calculated on the basis of the participant’s responses by

starting with factor analysis. The decision of number of factors in the scale was taken on

the basis of Eigen value, Scree Plot, and factor loading. Concurrent validity was

established by comparing the responses of participants for both the developing scale and

Inventory of Interpersonal Problems Short Form (IIP-SC) (Barkham, Hardy, & Startup,

59

1996). It was followed by assessing test re-test and split-half reliability. For test-retest

reliability the researcher chose 30 students who participated in the first administration of

the scale, and retested them two weeks from the day of first test.

Study II: Prevalence Study

This section describes the sampling technique, participants, measures, and the

procedure that was used to put through the prevalence study.

Participants. The participants were male Somali undergraduate university

students aged between 18 to 25 years old. To select the participants a multistage sampling

technique was used, and the sample size was chosen based on the formula of (Wackerly,

Mendenhall, & Scheaffer, 2014) and was calculated by Openepi version 3 (Dean,

Sullivan, & Soe, 2014). The largest of all the sample sizes (n=1153) was taken, which

was calculated by using the following single population proportion and assumptions:

95% confidence level, 1000000 reference population size, 50% expected prevalence of

Khat chewing (this expected percentage of prevalence was taken as there is no prevalence

study done in the past years in Somalia), a design effect of 1 for complex sampling, and a

5% anticipated nonresponsive rate.

The prevalence study took place in Amoud University, which is situated in

Borama city, in the northern region of Somalia (Somaliland). The university provides

many programs that include undergraduate diploma, bachelor degrees, master degrees,

and has three campuses. The prevalence study was done on only the four-year bachelor

degree programs. The bachelor programs in thirteen departments, and the total student

body of these classes 4246, all of whom are full time students. There are 2838 male

students, and 1408 female students. The study used cross-sectional research design, and it

60

took place from March 10, 2017, to May 2, 2017. The study included only male students,

to avoid response bias from female students as stigma is associated with the female that

chews Khat in Somalia (Kassim et al., 2015).

Procedure. To begin with the Amoud university administration was approached

and requested permission to collect data from the university students. They were told

about the nature and objectives of the study and a written permission was taken from

them (see appendix K). All participants were ensured about the confidentiality,

anonymity and the right to withdraw from the current research. Also, they were told the

purpose of the study and how the finding will be used. For sampling techniques, a two-

stage sampling scheme was carried out for the selection of participants in the prevalence

study. For the first stage, ten departments from undergraduate programs of Amound

University were selected through simple random sampling as primary sampling units.

The second stage (as secondary sampling unit), one section was selected randomly from

each year of study in each selected program if the number of sections was more than one.

In the end it was included in the study all male students in the selected sections, by

Keeping in mind the preferred method for school surveys (Bjarnason, 2003).

For collecting data, it was constructed a structured questionnaire. The tool was

made in English (see Appendix B) and then translated into Somali, which later back-

translated into English by an independent translator to compare the consistency of the

two English versions. The questions of the tool were mostly taken from a questionnaire

of the United Nations Office on Drugs and Crime (2003) for surveys of a student using

drugs. The tool consisted of items such as the necessary demographic details, khat

chewing habits, and other pertinent information. A pilot study of 30 university student

61

was conducted before the actual data collection, in order to assess the clarity and

understanding of the items in the questionnaire. Some of the items were rephrased based

on the suggestions taken from the students from the pilot study. After taking written

permission from the university, the students were approached while they were seated in

their classes. With the help of some of the university staff and other facilitators, spaces

were made between each two students in order to avoid working together when filling the

form. The students were told about the aims and objectives of the study; the reason for

their selection to the study; and how to fill the form. After the students understood the

study objectives and how to fill in the form, the questionnaire was distributed to them.

Only facilitators who were not familiar with the students monitored them. Variables such

as age, field of study, year of study, region of belonging, having father or brother or

friend who chewed khat, were used as an independent variable. Variables like Khat

related habit (life time chewed khat, life time smoking, frequency of chewing khat and

number of hours of chewing Khat per day) were taken as dependent variables (see

appendix B).

Study III: Comparison of Khat Users and Non-Khat Users

This section discussed the sampling technique, participants, and the procedure

that was employed to explore the differences between Khat users and non-Khat users for

the bases of personality traits, interpersonal difficulties and mental health problems.

Research design. A comparative cross-sectional research design was employed to

find out personality traits, interpersonal difficulties, and mental health problems that are

linked to Khat chewing. Cross-sectional research design helps to collect data of many

62

variables within one specific period. Although it cannot determine the causal relationship,

it can give useful information that will direct future researchers.

Participants. The participants were Somali male undergraduate university

students aged between 18 to 25 years old. Since the current research has been carried out

on two samples, therefore, two sampling techniques were used to recruit the participants

for the current research. In order to select Group 1, the Khat users, a snowball sampling

technique was used and Group 2, non-khat users, purposive sampling technique was

used. The sample size was 341, out of which 247 of them were Khat Users, while 94

were non-Khat users that were taken as controls. The sample size was established based

on the formula of Hair, Black, Babin, and Anderson (2010). According to this formula,

the sample size is calculated by multiplying minimum 3 and maximum 13 into the

number of items in the questionnaire that is used for the research. In this case the

researcher chose to multiply the number of items of the scale into 7, because number of

items on the scale is large.

Measures.

Demographic characteristics. Age, levels of undergraduate university, and

having parents or siblings who chew Khat were taken as demographic characteristics.

The characteristics of chewing Khat (frequency of chewing Khat, chronicity, duration of

Khat session per day, and chewing Khat alone or in-group) were also included (see

appendix C).

Khat Interpersonal Difficulties Scale (KIDS). The newly developed KIDS was

used for measuring interpersonal difficulties among Khat users. KIDS comprised 33

difficulties as experienced and expressed by Khat users. The instructions for KIDS were:

63

“Following are some characteristics of people who use Khat. Please read each item

carefully and judge the extent to which it applies to you. There are four options to choose

from, circle only one option on each statement that applies to you”. The scoring options

included (0) not at all, (1) sometimes, (2) often, (3) always. High score represented more

interpersonal difficulties an individual experienced. Concurrent validity KIDS and

Inventory of Interpersonal Problems Short Circumplex (IIP-SC) (Barkham, Hardy, &

Startup, 1996) had significant positive correlation r=0.79 (p<0.001). Test-retest reliability

r= 0.85 (p<0.001), split-half reliability factor one (personal related) r= 0.77 (p<0.001),

and factor two (Khat related) r=0.74 (p<0.001) (see appendix E).

Eysenck Personality Questionnaire Revised-Short Form (EPQR-S). EPQR-

Short (Eysenck, Eysenck, & Barrett, 1985) is a self-reported questionnaire. It consists of

48 items with 12 items for each subscale such as Extraversion, Neurosis, Psychosis, and

Lie Scale, and the response of each question is either ‘Yes’ or ‘No'. The score is 1 or 0,

and the score of each subscale is range from 0 to 12. The reliabilities of subscales for

males and females respectively of 0.88 and 0.84 for extraversion, 0.62 and 0.61 for

psychoticism, 0.84 and 0.80 for neuroticism, and 0.77 and 0.73 for the lie scale. For test-

retest reliability, the EPQ-R Short subscales have good reliability for neuroticism is 0.86,

psychoticism 0.78, extraversion 0.89, and Lie Scale 0.84. Interior consistency was

roughly 0.80 for the three major subscales (Aiken, 1989; Rodgers, 1995) (see appendix

G).

Depression Anxiety Stress Scale (DASS). The DASS (Lovibond & Lovibond,

1995) is a self-report tool consists of 21 items, which divided into three subscales

(Depression, Anxiety, and Stress) with 7 items each. The rating of each item is a 4 points

64

scale include (0) not at all, (1) sometimes, (2) often, (3) always. The internal consistency

of subscales was found to be depression .90, anxiety .92, and stress .92. For the three

subscales, the test-retest reliability scores were found to be .98. The criterion-related

validity for DASS correlated with Beck Anxiety Inventory (Beck, Epstein, Brown, &

Steer, 1988), and Beck Depression Inventory (Beck, Steer, & Brown, 1996) were .84 and

.87 respectively. (see appendix F).

Procedure. The data was collected from the University of Hargeisa and Gollis

that are situated in Hargeisa, the second largest city in Somalia. The Institutional Ethical

Committee approved all study procedure. The study was conducted fulfilling all ethical

considerations at every step. All participants were ensured about the confidentiality,

anonymity and the right to withdraw from the current research. Also, the students were

told the purpose of the study and how the finding will be used. Chewing Khat at the

student level is associated with social stigma and most of the students used to hide their

habit to avoid punishment from their parents. For that reason, it was difficult to approach

the students on university campuses, and the only way to collect data from them was to

ask students to tell their friends who chew Khat. After ensuring the confidentiality, the

students who admitted using Khat accepted to participate in the study and further referred

to other students who chew Khat. The participants were approached in groups of eight to

ten to ensure the confidentiality and to avoid the response biases. Only students who

consume khat at least once a week were included. On the other hand, those students who

never chew Khat in their lifetime were recruited as non-Khat users in the study. The

participants were divided equally into the four levels of undergraduate and then was

approached in the campus of the universities. The researcher collected the data for the

65

any student who meet the criteria until the required sample was completed. The

participant of this group were also approached in a group of three or more. Both groups

were matched by age, gender, level of education, and geographic area. The participants

were given three scales that included EPQR-Short ((Eysenck, Eysenck, & Barrett, 1985)

KIDS, and DASS (Lovibond & Lovibond, 1995), and were then requested to fill the

questionnaires, by starting from the demographic sheet and followed by the three scales.

SPSS version 21.0 was used to analyze the data. A debriefing session was carried out at

the end of each testing and participants were asked for any inquiry, question, or feedback.

Study IV: Intervention Study

The last section discussed the sampling technique, participants, and the procedure

that took place to examine the efficacy of cognitive behavior therapy for the habit of Khat

chewing.

Research design. A pretest-posttest experimental design was applied to find the

effectiveness of cognitive behavior therapy for Khat Users. A pretest-posttest experiment

design gives the researcher ability to see how the two groups changed from pretest to

posttest. If the control group showed a significant improvement on posttest, the

researcher has a chance to find the reason behind it. Finally, it gives chance to compare

the results of pretest between groups to see the effectiveness of randomization, and this

helps to control the confounders (Dimitrov & Rumrill 2003).

Participants. A 40 Somali undergraduate students that regularly use Khat and

have a motivation to stop chewing Khat as they told to the researcher were recruited from

university campuses, through snowball sampling. University students were chosen for the

investigation since they can without much of a stretch grasp the language of the scale in

66

English. A matching method were used and the participants of both groups were similar

in age, chronicity of Khat use, Khat chewing behavior, types of Khat chewed, and all

were undergraduate students. Inclusion criteria were made and those students that

regularly chewing Khat with at least once a week, and not experiencing active psychosis

were included in the study. Besides chewing khat, the participants were also cigarette

smokers. Cigarette smoking is highly associated with regular Khat chewers, especially in

young people (Kebede, 2002) and for that reason, it was difficult to exclude. The study

also included only male students as they have high proportions of Khat chewing and as

stigma is associated with the female that chews Khat in Somalia, which made difficult to

include them in the study (Kassim et al., 2015). Random assignment was deployed

through lottery method to divide the sample into those receiving CBT and those receiving

Psycho-education. Each group of the study had 20 participants.

Procedure. The study was taken place in Borama, a city in northern Somalia

(Somaliland). All procedures of the study were approved by the Institutional Ethical

Committee before conducting data collection. After recruiting the participants, they were

told the purpose and the benefits of the study, and written inform consent were taken

from them (see Appendix J). The scales used for this study are Khat Interpersonal

Difficulties Scale (KIDS) and Depression Anxeity, and Stress Scale (DASS). The

participants were 40 Khat users from university students, and were divided equally into

the two treatment groups through random assignment. Only the students who used Khat

regularly were selected as participants in the experiment study. The first group received

three sessions on addictive psychoeducation, and they were given a general overview

about the processes of addiction, risk factors that increase the chances of dependency,

67

and the biopsychosocial effect of Khat. Each session lasted 90 minutes and all 20

participants were in one group. For a guidance it was used “Staying sober: A guide for

relapse prevention” (Gorski & Miller, 1986). One month after the three session were

done, the group was tested again with the same areas that were tested before the therapy.

The other group received manualized cognitive behavior therapy. The therapy

consisted of 7 sessions, group-administered therapy that was approximately 90 min and

based on clinical procedures described in a treatment manual for drug addiction (Carroll,

1998). Four treatment groups were made with five participants each, and the therapy

continued for one month with a 4 days’ gap between each two sessions. The therapy was

administered by a trained clinical psychologist and two facilitators. There was one

baseline that measured the level of Khat chewing and mental health problems. 15 days

after the therapy was completed, it was tested again with the same area and compared the

pretest and posttest. At the end, the two groups were compared based on their

performance on pretest and posttest for both mental health problems and Khat chewing

behavior. There were no dropouts throughout the study as the participants were promised

an incentive at the end of the study. The structure of manualized CBT sessions was as

follows:

Session one: introducing the therapy. The goals of the session were to build

a rapport, enhance motivation, negotiate treatment goals, establish treatment rules, and

introducing functional analysis with the clients. The therapist obtained the clients history

of their substance use, their level of motivation, and their interest in continuing the

therapy program. Moreover, the therapist introduced the goals of therapy and negotiated

with them the rules they needed to follow during each session. Most of the participants

68

were motivated to take part in the therapy. However, a few participants questioned the

therapist to enlighten them more about the benefits of therapy. The therapist answered all

their inquiries and showed his wiliness to respond any of their queries. At the end, the

therapist gave an assignment to the participants and made sure that the participants

understood the advantages and goals of the therapy, rules of the sessions, and the

schedule of the next session.

Session two: coping with craving. The session was intended to understand,

describe, and identify triggers or cues of craving. Copying with cravings included by

teaching participants the techniques of distraction, talking about craving, going with the

craving, recalling the negative consequences of substance use, and self-talk.

Understanding cravings and learning ways to deal with it helps the clients to continue

abstaining from the substance for a longer period. For that reason, the therapist discussed

in detail the triggers and how to cope with cravings, as well as, gave relevant examples to

the participants. For practice in understand cravings, the therapist asked the participants

to share their experience about craving Khat. Some of the participants were outgoing and

gave more examples about their experience for craving Khat. However, in order to make

sure the clients understood craving, the therapist requested each participant to give at

least of one example about his experience of craving Khat. After assisting, all participants

gave examples about their experience of craving Khat. At the end of the session, the

therapist gave some exercises to master the techniques used to deal with cravings.

Session three: assertive training. The purpose of the session was to teach

assertiveness to the clients. A major issue with users is difficulty in refusing offers of the

substance of abuse. Many abusers used social networks that are very narrow and include

69

few non-users, so that, to refuse the offers from their abuser friends will cause the person

to be rejected which leads to loneliness. This makes them vulnerable to accept

suggestions made by their friends. Thus, this session included, training in assertive skills

and social skills in general. Teaching social skills can help the participants to expand

their social networks and decreases the stress related to social rejection. For that reason,

the therapist demonstrated the way drug users influence each other to the participants

with a role play during the session. During the session one of the participants received

call from one of his Khat chewing friend and was offered by Khat. He shared the craving

and the feeling he experienced after being offered Khat. The incident gave chance for the

therapist to demonstrate craving and the influence of substance use friends. He also

taught them social skills. The participants understood and some of them told their stories.

At the end of the session, the therapist gave an exercise and requested them to note down

when they experience cravings or peer pressure.

Session four: safe decision making. As the therapy progressed and the clients

learnt to counter the situations that are directly related to using the substance, the

therapist started to teach them how to avoid the things that are indirectly related to it. One

of these associated conditions is making seemingly irrelevant decisions like rationalizing

the usage, minimizing the risk of the substance, and taking part in high risk situations

because they believe it is easy to handle. Working with these seemingly irrelevant

decisions emphasizes the cognitive aspects of the therapy. It will help them to possess

intact cognitive functions and some ability to reflect upon their cognitive and emotive

lives. The therapist explained the importance of avoiding making these decisions and

asked the clients to give more examples. One of the examples that the participants told

70

was staying or going to the market at noon (which is the time that most people buy Khat).

The participants understood the importance of avoiding these decisions and in the end the

therapist told them to continue recording their progress.

Session five: coping skills. This session deals with preparing the participants to

cope stressful situations. Regardless of individual’s efforts to overcome substance use,

unexpected conditions may emerge that may undermine the therapy and can lead the

individual to start the substance again. These frequently need to do with real, negative

distressing occasions or emergencies; for example, the passing or sickness of a friend or

family member, learning one is HIV positive, the loss of an important relationship, and so

on. Nonetheless, positive occasions can likewise prompt similar circumstances, which

can be including getting much cash or beginning a new love relationship. Since such

occasions may happen anytime within therapy or after the therapy, participants are urged

to build up a coping mechanism which they can allude to and utilize if such emergencies

happen. Thus, the objective of the session was preparing the participants for future high-

risk situations and building up an adapting plan that suited the individual's circumstance.

Therapists asked the participants to think of three or four significant stressors that had

happened before and increased their substance use. Then, the therapist explained the

relationship between stress and substance use and worked with them to develop concrete

coping plans. In the end, the therapist told the participants to practice these coping

strategies.

Session six: problems solving skills. The session provided a basic strategy that

can be applied to a range of problems related to substance use, as well as, the variety of

problems that can invariably arise after clients leave treatment. Over time, many patients’

71

repertoires of coping and problem-solving skills have narrowed such that substance abuse

has become their single, overgeneralized means of coping with problems. Many patients

are unaware of problems when they arise and ignore them until they become crises. So,

the therapist introduced them to the basic steps of problem solving, and allowed the

participants to practice during the session. The therapist told them that having a problem

can make one anxious, so, effective problem-solving takes time and concentration, and

the impulsive first solution is not necessarily the best. The therapist asked patients to

identify two recent problems, and worked with them through solving it. Most of the

participants mentioned at least one problem that was either ongoing or one that was in the

past and the therapist assisted them to solve them whilst applying the skills they learnt

from the therapy program.

Session seven: case management. Most of the time user individuals come for the

therapy with a range of concurrent psychosocial problems in addition to the use of the

substance. This session included identifying psychosocial problems participants were

experiencing; reviewing and applying problem solving skills to intervene these problems;

developing a concrete plan for addressing psychosocial problems. The therapist

continued to help the participants apply the problem-solving skills during the session.

Finally, the therapist terminated the therapy program by summarizing the goals of the

therapy, and discussing with the participants the progress and changes they had

experienced. The participants said that they learnt many ways to maintain abstinence of

Khat dependence. Lastly, the therapist requested the participants to fill the form that

consisted Khat related behavior, Khat Interpersonal Difficulties Scale (KIDS), and

Depression Anxiety, Stress Scale (DASS).

72

Chapter IV

Results

This chapter of the study highlighted the results of all the four studies that were

taken place. It is divided into four sections. First, it was displayed the psychometric

properties of the developed scale, which included the result of factor analysis, concurrent

validity, test re-test reliability, and split-half reliability. Second, the prevalence study was

shown by starting the demographic characteristics of participants, the prevalence of

chewing Khat among the students, and factors that are related to lifetime chewing Khat.

Third, the cross-sectional study which was the main study was presented, and

demographic characteristics, testing the primary and secondary hypotheses were

included. Lastly, the result of the experimental study was revealed, in which the

researcher started to demonstrate the characteristics of participants and then show the

result of the comparison between the treatment group and the control group.

Section I: Psychometric Properties of the Khat Interpersonal Difficulties Scale

(KIDS)

Section II: Prevalence Study

Section III: Main Study

Section IV: Experiment Study

73

Section I: Psychometric Properties of the Khat Interpersonal Difficulties Scale

(KIDS)

This section consists of factor analysis, concurrent validity, split half reliability,

and test-retest reliability that discusses as follows:

Factor analysis. The study used Principle Component Factor Analysis with

Varimax Rotation to perform on 38 items of Khat Interpersonal Difficulties Scale

(KIDS). The Varimax Rotation was used in order to maximize the orthogonal,

interpretability, classifications, and maximize the variance of factors. The criteria that

used to determine number of factors were as follows:

1. The Scree Plot was used to identify the factor structure of the scale. This idea was

introduced by Cattell (1966). The Scree Test is the graphical representation of

Eigen values.

2. Eigen Value of > 1: This is one of the most popular methods to determine the

number of factors, based on the assumption to retain factors with the Eigen value

greater than 1.

74

Factor Analysis of Khat Interpersonal Difficulties Scale (KIDS)

Figure 1: Scree Plot Showing Extraction of factors of Khat Interpersonal Difficulties

Scale (KIDS) of the participants (N=200)

To selecting the items of KIDS, it was used the Kline (2014) criteria which says

only the items with a factor loading of 0.30 or greater can be chosen in the scale. The

above Scree Plot is showing that the scale can be up to 6 factors. However, it did not fit

after tried 6, 5, 4, and three factors solutions with 0.30 or 0.40 loading, as it showed many

overlapping and lack of conceptual clarity. Then, the researcher tried two-factor solutions

with 0.40 that indicated no overlapping and showed conceptual clarity. A total of 18

75

items were loaded on the first factor, and 15 items were listed under the factor two, while

the remaining five items were discarded as they did not load any of the two factors. The

factor loadings of 33 items with their respective themes were given in Table 1.

Table 1

The Factor Structure of 33 Items of Khat Interpersonal Difficulties Scale (KIDS) with

Varimax Rotation

S. No Items Factor 1 Factor 2

1 19 .41 .28

2 22 .52 .28

3 23 .46 .19

4 24 .44 .35

5 25 .46 .31

6 26 .44 .31

7 27 .58 .21

8 28 .59 .29

9 29 .57 .18

10 30 .60 .23

11 31 .64 .21

12 32 .53 .23

13 33 .66 .27

14 34 .64 .19

15 35 .54 .18

16 36 .47 .30

17 37 .48 -.00

18 38 .71 .09

19 1 .23 .51

20 2 .09 .66

21 3 .22 .42

Continue…

76

22 5 .34 .46

23 6 .39 .49

24 7 .22 .57

25 8 .15 .44

26 9 .09 .57

27 11 .23 .53

28 12 .18 .50

29 13 .34 .45

30 14 .20 .60

31 15 .36 .51

32 16 .21 .48

33 18 .30 .46

Note: factor loadings >.40 have been boldfaced.

Table 2

Eigen Values and Variance Explained by Two Factors (Personal Related and Khat

Related) of Khat Interpersonal Difficulties Scale (KIDS)

Factors Eigen value % of Variance % of total Variance

1 6.82 17.94 17.94

2 5.43 14.29 32.23

Table 2 presented the factorial structure of KIDS. A descriptive label was carried

out to each of the two factors by shared characteristics, and a copy of the list of items is

given to appendix F. The details of these two-factor descriptions were given below:

Factor 1: person related. The first factor was labeled “person related” because

the items were displaying some form of negative few about oneself that contributed to

have interpersonal difficulties. It consisted 18 items including, “I feel suspicious of

77

others,” “I tell lies,” “I ask money from others,” “I break promises,” “I have no goal in

life” and “I fight easily.”

Factor 2: Khat related. The second factor contains 15 items that categorized as

Khat related interpersonal difficulties. Examples of items include “I cannot do anything

without chewing Khat,” “I make mistakes at work,” “I become angry easily,” “I do not

talk to others,” “I avoid people I respect,” and “I feel tension.”

Internal consistency of Khat Interpersonal Difficulties Scale (KIDS).

Table 3

Cronbach Alpha of Total Items of Khat Interpersonal Difficulties Scale (KIDS) and the

Two Factors (Personal Related and Khat Related) Separately

Factors No of items

I Personal Related 18 .89

II Khat Related 15 .85

Total KIDS Score 33 .92

Note: = Cronbach alpha, KIDS= Khat Interpersonal Difficulties Scale

The table 3 displayed that KIDS items have high internal consistence for the value

of 0.92. It presented the homogeneity of the total items, as well as the items of each

factors separately.

Intercorrelations between factors of Khat Interpersonal Difficulties Scale

(KIDS). For the reason to find the relationship of the factors, inter-correlation was

calculated.

78

Table 4

Summary of Intercorrelation, Means, and Standard Deviations for Scores on Two factors

(Personal Related and Khat Related) of Khat Interpersonal Difficulties Scale (KIDS)

Factors Factor 1 Personal

Related

Factor 2 Khat Related Total Scores

Personal

Related

--- .71*** .94***

Khat Related --- --- .91***

Total Scores --- --- ---

M 22.48 18.87 41.35

SD 10.99 8.98 18.49

Note: df=200, significant is displayed in the table, ***p<0.001, M= mean, SD= Standard deviation

The table 4 revealed that there are significant positive relations among two factors

of KIDS (Personal Related and Khat Related) on a value of 0.71 (p<0.001).

Concurrent validity. For the purpose to find the concurrent validity of Khat

Interpersonal Difficulties (KIDS), it was used Inventory of Interpersonal Problems Short

Circumplex (IIP-SC) (Barkham, Hardy, & Startup, 1996). The IIP-SC consists of 32

items that divided into eight subscales: domineering, vindictive, cold, socially avoidant,

non-assertive, exploitable, overly nurturant and intrusive, each containing four items. For

measuring the concurrent validity of KIDS, it was given to KIDS and IIP-SC together of

200 participants. The result revealed that KIDS and IIP-SC had significant positive

correlation r=0.79 (p<0.001).

Split-half reliability. Split-half reliability of Khat Interpersonal Difficulties Scale

(KIDS) was carried out in order to find the internal consistency of the items of the scale.

The scale consists of two factors that named “personal related” and “Khat related.” The

researcher calculated split-half reliability for each factor separately. To do so, the items

79

of each factor was listed by the highest loading order, and then, allocated into two parts

by using the Odd and Even method. Later, the researcher correlated the two parts of each

factor, and the finding revealed that the split-half reliability of factor one (personal

related) r= 0.77 (p<0.001), and factor two (Khat related) r=0.74 (p<0.001).

Test-retest reliability. Test-retest reliability was employed to find out the

reliability of the Khat Interpersonal Difficulties (KIDS). About 20% of the 200

participants were given second time to the scale after a week or so from the first test day.

Subsequently, the researcher correlated the outcome of the two attempts, and the finding

showed significant positive correlation r=0.85 (p<0.001).

80

Section II: Prevalence Study

Prevalence study was analyzing by showing the demographic characteristics of

participants, prevalence of chewing Khat among the students, and factors that are related

to lifetime chewing Khat.

Table 5

Frequencies and Percentage of Prevalence Study Characteristics of the Participants

(N=1153)

Variables f(%)

Age

18-20 345 (29.82)

21-23 512 (44.41)

24+ 296 (25.67)

Field of Study

Science 717 (62.19)

Arts 129 (11.19)

Freshman 307 (26.62)

Education

BS Year I 307 (26.62)

BS Year II 319 (27.67)

BS Year II 301 (26.11)

BS Year IV 226 (19.60)

Region of Belong

Somaliland 939 (81.44)

Puntland 120 (10.41)

South-central Somalia 94 (8.15)

Life Time Smoking

Yes 270 (23.42)

No 883 (76.58)

81

Has a Father Who Chew Khat

Yes 517 (44.84)

No 636 (55.16)

Has Sibling/s Who Chew/s Khat

Yes 343 (29.75)

No 810 (70.25)

Has a Friend/s Who Chew/s Khat

Yes 598 (51.86)

No 555 (48.14)

Note: f=frequency, %= percentage, BS= Bachelor of Science

Table 5 showed the frequency and percentage of socio-demographic

characteristics of the participants of the prevalence study. The students were grouped into

three ages intervals that include 29.82% (345/1153) were between the age ranges 18 to 20

years old, 44.41% (512/1153) between 21 to 23 years old, and 25.67% (296/1153) above

the age of 24 years old. The majority of the students belonged to science departments

62.19% (717/1153), Somaliland region 81.44% (939/1153), not smoked any time in their

life 76.58% (883/1153). The proportions of education levels were almost equal of the

number of participants in which in 26.62% studying year one, 27.67%, year two 26.11%

year three, and 19.60% year four. Out of 1153 students, 44.84% (517/1153) have a father

who chews khat, 29.75% (343/1153) have siblings/s who chew/s khat, and 51.86%

(598/1153) have friend/s who chew/s khat.

82

Table 6

Prevalence of Chewing Khat among Undergraduate Amoud University Students of the

Participants (N=1153)

Variables f(%)

Life Time Prevalence 339 (29.40)

Current Users 196 (16.99)

Less Than 30 days 61 (5.30)

Less Than 1 Year 65 (5.60)

1-3 Years 28 (2.40)

4-6 Years 20 (1.70)

6+ Years 20 (1.70)

Note: f=frequency, %= percentage

Table 6 revealed that 29.4% (339/1153) of Amoud University students chewed

Khat at least one time in their life. About 17% (196/1153) of total students were current

Khat chewers of whom the majority of them started chew Khat less than a year.

83

Table 7

Frequencies and Percentage of Patterns of Chewing Khat in among the Current Khat

Chewer Students of Amoud University of a Participants (N=196)

Patterns of Chewing Khat f(%)

Mode of Chewing Khat

Used Khat Alone 43 (22.16)

Used Khat with Group 151 (77.84)

Hours of Chewing Khat per Day

1-4 Hours Per Day 100 (51.55)

5-8 Hours 59 (30.41)

8+ Hours 35 (18.04)

Frequencies of Chewing Khat

Once a Week 98 (50.52)

2-4 Days Per Week 61 (31.44)

Daily 35 (18.04)

Type of Khat Chewed

Daba Musbaar 37 (19.07)

Jabis 120 (61.86)

Dadar 5 (2.58)

Boondaro 9 (4.63)

Others 23 (11.86)

Getting income from

Jobholder 47 (24.23)

Family 44 (22.68)

Relative 14 (7.21)

Friends 63 (32.47)

Others 26 (13.40)

Note: f=frequency, %= percentage

Table 7 indicated the patterns of chewing Khat among the students who chew

Khat regularly. Firstly, most of the students stated for using Khat in group 77.84%

84

(151/194), and spend chewing Khat up to four hours a day 51.55% (100/194). Secondly,

the majority of the students’ chew Khat once a week 50.52% (98/194) and chew a type of

Khat called by Somalians (Jabis) 61.86% (120/194) which is from Harar District in

Ethiopia. Finally, the students received most of the income they use for purchasing Khat

from friends 32.47% (63/194), family 22.38 % (44/194), and some of them are jobholders

24.23 % (24.23).

Table 8

Factors Associated with Life Time Chewing Khat among the Students of Amoud

University of the Participants (N=339)

Life Time Prevalence of Chewing Khat

Yes No

Factors f (%) f (%) χ2 φ p<

Life Time Smoking

Yes 213 (78.90) 57 (21.10) 410.70 .60 .001***

No 127 (14.20) 756 (85.80)

Has a Father Who Chew Khat

Yes 177 (34.20) 340 (65.80) 9.75 .09 .005**

No 163 (25.60) 473 (74.40)

Has Siblings Who Chew Khat

Yes 138 (40.20) 205 (59.80) 26.38 .15 .001***

No 202 (24.90) 608 (75.10)

Has a Friend Who Chew Khat

Yes 266 (44.50) 332 (55.50) 134.20 .34 .001***

No 74 (13.30) 481 (86.70)

Note: f=frequency, %= percentage, df=1, significant of the result showed in the table **p<0.001,

***p<0.001, χ2= chi square, φ= phi coefficient (the strength of correlation between the two variables)

85

Table 8 indicated there was a strong relationship between smoking and chewing

khat. Those students who smoke had most probably chewed Khat as well. Furthermore,

having a friend or father or siblings who chew Khat was significantly predicting for the

person to start chewing Khat.

86

Study III: Comparison of Khat Users and Non-Khat Users

On main study a cross-section study was carried out which was tested both the

primary and secondary hypotheses, and the results are displayed below by starting the

demographic characteristics of the participants in the main study.

Table 9

Means, and Standard Deviations of Age of the Participants Khat Users (n=247), and

Non-Khat Users (n=94)

Variables

Khat Users Non-Khat Users

M SD M SD

Age in Years 23.03 2.01 21.44 1.71

Note: M= mean, SD= Standard deviation

Table 9 exhibit that the mean age of the Khat Users participants 23.03±2.01 was

slightly more than the mean age of non-Khat Users participants 21.44±1.71. Also, the

margin of difference in standard deviation between groups is less, which shows that most

of the participants of both groups are between 20 to 24 years old.

87

Table 10

Frequencies and Percentage of Four Levels of Undergraduate University of the

Participants Khat Users (n=247), and Non-Khat Users (n=94)

Groups

Khat Users Non-Khat Users

Variables f (%) f (%)

BS-I 70 (81.40) 16 (18.60)

BS-II 51 (65.40) 27 (34.60)

BS-III 58 (71.60) 23 (28.40)

BS-IV 68 (70.80) 28 (29.20)

Note: f=frequency, %= percentage, BS= Bachelor of Science

The table 10 revealed that a similar representation of the levels of undergraduate

university students in each group. This shows that the two groups are comparable

regarding the percentage representation of each level of undergraduate.

88

Table 11

Frequencies and Percentage of Patterns of Chewing Khat of Only Khat Users Group of

Participants (n=247)

Variables f (%)

Frequency of Chewing Khat

Daily 53 (20.50)

Four Times a Week 73 (28.30)

Twice a Week 66 (25.60)

Once a Week 66 (25.60)

Duration of Chewing Khat

Less than 1 year 62 (24.00)

1-3 years 83 (32.20)

4-6 years 53 (20.50)

More than 6 years 60 (23.30)

Hours of Chewing Khat per Day

1-4 hours 102 (39.50)

5-8 hours 73 (28.30)

More than 8 hours 83 (32.20)

Type of Khat Chewed

Daba Musbar 74 (28.70)

Jabis 148 (57.40)

Dadar 11 (4.30)

Boondaro 9 (3.50)

Others 16 (6.20)

Pattern of Chewing Khat

Alone 34 (13.20)

In-group 224 (86.80)

Note: f=frequency, %= percentage

Table 11 showed the frequency and percentage of patterns of Khat chewing

among the Khat Users group. The participants chew Khat at least once a week, and 1-4

hour a day, and most of them have been chewing Khat at least one year. Majority of them

89

also use a type of Khat Somalis called (Jabis) 57.4 (148/247), and chew Khat in a group

86.8% (224/247).

Testing the main hypotheses. This section deals the comparison between Khat

users and non-Khat users on the personality traits, interpersonal difficulties, and mental

health problems. The personality traits were measured Eysenck Personality Questionnaire

(EPQ) which consists of four factors Extroversion, Neuroticism, Psychoticism, and Lie

Scale. Interpersonal difficulties were quantified by newly developed Khat Interpersonal

Difficulties Scale (KIDS) that comprises two sub-scales Person-related and Khat-related

interpersonal difficulties. Finally, mental health problems were calculated on the bases of

Depression Anxiety Stress Scale (DASS) that composes of three sub-scales as indicated

by the name Depression, Anxiety, and Stress.

Hypotheses:

11. It is hypothesized that those students who chew Khat would experience more

interpersonal difficulties and mental health problems as compared to those

students who don’t chew Khat.

12. It is hypothesized that there would be difference on personality traits between

students who chew Khat and those who don’t.

In order to test the above hypotheses, the researcher employed t-test to compare

the means of the two groups (Khat users and non-Khat users).

90

Table 12

Means, Standard Deviations, t-test and p-values of Comparing the Khat Users and Non-

Khat Users on the Two Factors (Personal Related and Khat Related) and Total of KIDS,

Three Factors (Depression, Anxiety, and Stress) and Total of DASS, and Four Factors of

EPQRS (Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the Participants

(N=341)

Groups

Khat Users

(n=247)

Non-Khat Users

(n=94)

Variables M SD M SD T p<

Personal Related 23.54 10.39 11.42 10.49 9.59 .001***

Depression 8.68 4.03 4.02 3.76 9.69 .001***

Anxiety 9.33 3.94 4.35 3.38 10.83 .001***

Stress 9.41 3.84 4.36 3.33 11.23 .001***

DASS Total 27.42 10.65 12.73 9.08 11.83 .001***

Extraversion 6.64 2.24 7.03 2.05 1.46 .145 ns

Neuroticism 6.46 2.94 4.86 3.02 4.45 .001***

Lie scale 5.37 2.10 6.00 2.36 2.38 .018**

Psychoticism 5.06 1.87 4.41 1.76 2.92 .004**

Note: df=339, significant are presented in the table, *p<0.01, **p<0.001, KIDS= Khat Interpersonal

Difficulties Scale, DASS= Depression, Anxiety, and Stress Scale, EPQRS= Eysenck Personality

Questionnaire Short Form

Table 12 indicated that students who use Khat experience more interpersonal

difficulties and mental health problems than students who don’t use Khat. Moreover,

Khat users were higher on Neuroticism and Psychoticism personality traits than non Khat

users. However, non Khat users were slightly higher on Lie scale than khat users and

there were no significant differences on Extroversion personality traits.

The predictors of interpersonal difficulties and mental health problems. This

portion deals with finding the predictors (personality traits and patterns of Khat chewing)

91

of interpersonal difficulties and mental health problems on students who use Khat. The

researcher used to measure personality traits on (EPQ), interpersonal difficulties on

(KIDS), and mental health problems on (DASS).

Hypothesis 3: It is hypothesized that those students who scored high on

neuroticism, psychoticism, use Khat more hours a day, and chew Daba Musbar (the

strongest type of Khat in the region) would have more interpersonal difficulties.

To test this hypothesis, the researcher used hierarchical regression analysis to find

out the predictors of interpersonal difficulties.

92

Table 13

Hierarchical Regression Analysis of Predictors of Interpersonal Difficulties of Khat

Users of Participants (N=247)

Model SEB B Β T p<

Step 1: R= .12 R2=.12

Step 2: R= .40 R2=.27

Step 1

Age in years 1.21 .48 .13 2.54 .012*

Years of University -1.03 .76 -.06 -1.36 .175 ns

Step 2

EPQ-Ext .12 .41 .01 .28 .778 ns

EPQ-Neu 1.75 .34 .27 5.16 .001***

EPQ-Psy 2.02 .48 .19 4.18 .001***

EPQ-Lie .23 .45 .03 .52 .604 ns

Frequency of chewing Khat .08 .91 .01 .08 .933 ns

Chronicity of chewing Khat .07 1.08 .01 .06 .949 ns

Hours of Khat chewing per day 4.42 1.44 .24 3.07 .002**

Type of Khat chewed 3.17 1.00 .19 3.16 .002**

Pattern of chewing Khat .02 2.14 .01 .01 .993 ns

Parent or siblings chew Khat 1.02 2.25 .03 .45 .651 ns

Note: significances are presented in the table, *p<0.05, **p<0.01, *** p<0.001

EPQ-Ext= Eysenck Personality Questionnaire (Extraversion sub-scale), EPQ-Neu= Eysenck Personality

Questionnaire (Neuroticism sub-scale), EPQ-Psy= Eysenck Personality Questionnaire (Psychoticism sub-

scale), EPQ-Lie= Eysenck Personality Questionnaire (Lie scale)

Hierarchical regression analysis was used to assess the ability of characteristics of

Khat chewing and personality traits (Extraversion, Neuroticism, Psychoticism, and Lie

scale) to predict the interpersonal difficulties related to using Khat, after controlled age

and levels of the university. Age and university levels were entered at Step 1, explaining

12% of the variance in interpersonal difficulties. After entry of the characteristics of

chewing Khat and personality traits at Step 2, the total variance explained by the model

as a whole was 40%, F (13, 327) = 16.40, p< .001. The main predictors in step 2

93

explained an additional 27% of the variance in interpersonal difficulties, after controlling

for age and university levels, R squared change = .27, F change (11, 327) = 13.32, p <

.001. In the final model, Age, Neuroticism, Psychoticism, Hours of chewing Khat per-

day, and types of Khat chewed were significant predictors of interpersonal difficulties

related to Khat.

Hypothesis 4: It is hypothesized that those students who scored high on

extroversion, neuroticism, psychoticism, and chew Daba Musbar (the strongest type of

Khat in the region) would experience more mental health problems.

Hierarchical regression analysis was used to find out the predictors of mental

health problems.

94

Table 14

Hierarchical Regression Analysis of Predictors of Mental Health Problems Users of

Participants (N=247)

Model SEB B Β T p<

Step 1: R= .09 R2=.09

Step 2: R= .41 R2=.32

Step 1

Age in years .40 .29 .07 1.38 .168 ns

Years of University -.45 .46 -.04 -.99 .324 ns

Step 2

EPQ-Ext 1.14 .21 .29 5.56 .001***

EPQ-Neu 1.14 .21 .29 5.56 .001***

EPQ-Psy 1.63 .29 .25 5.57 .001***

EPQ-Lie .50 .27 .09 1.84 .066 ns

Frequency of chewing Khat -.37 .55 -.05 -.67 .502 ns

Chronicity of chewing Khat .03 .65 .01 .05 .959 ns

Hours of Khat chewing per day 1.60 .87 .14 1.84 .067 ns

Type of Khat chewed 1.93 .61 .19 3.18 .002**

Pattern of chewing Khat 1.95 1.29 .14 1.50 .133 ns

Parent or siblings chew Khat 1.18 1.36 .05 .87 .387 ns

Note: significances are presented in the table, **p<0.01, *** p<0.001

EPQ-Ext= Eysenck Personality Questionnaire (Extraversion sub-scale), EPQ-Neu= Eysenck Personality

Questionnaire (Neuroticism sub-scale), EPQ-Psy= Eysenck Personality Questionnaire (Psychoticism sub-

scale), EPQ-Lie= Eysenck Personality Questionnaire (Lie scale)

Hierarchical regression analysis was used to assess the ability of characteristics of

Khat chewing and personality traits (Extraversion, Neuroticism, Psychoticism, and Lie

scale) to predict the mental health problems, after controlled age and levels of the

university. In step 1 Age and university levels were entered, which explained 9% of the

variance in mental health problems, whereas step 2 was entered the characteristics of

chewing Khat and personality traits and the model explain 41%, F (13, 327) = 17.58, p<

.001of total variance. The main predictors in step 2 explained an additional 32% of the

95

variance mental health problems, after controlling for age and university levels, R

squared change = .32, F change (11, 327) = 16.24, p < .001. On individually,

Extraversion, Neuroticism, Psychoticism, and types of Khat chewed in the second model

were significant predictors of interpersonal difficulties related to Khat.

Interpersonal difficulties as a mediator for the relationship between personality

traits and mental health problems. Mediation analysis was employed to determine the

mediating relationship of interpersonal difficulties between personality traits and mental health

problems. The scales used were Eysenck Personality Questionnaire EPQ-Short Form for

measuring personality, Khat Interpersonal Difficulties Scale Total (KIDST) for interpersonal

difficulties, and Depression Anxiety Stress Scale Total (DASST) for mental health problems.

Hypothesis 5: It is hypothesized that experiencing interpersonal difficulties is partially or

fully mediate the relationship between personality traits (Neuroticism and Psychoticism) and

mental health problems.

This mediation analysis was demonstrated using Process Software for Regression

Analysis in IBM SPSS version 21. It was investigated that Neuroticism and Psychoticism

personality traits affect mental health either directly or through interpersonal difficulties.

X (IV)= Personality traits (Neuroticism and Psychoticism), M (Mediator)= Interpersonal

Difficulties (KIDST), Y(DV)= Mental Health Problems (DASST).

96

Table 15

Mediation Effect of Interpersonal Difficulties on the Relationship between Personality Traits and

Mental Health Problems of Khat Users Participants (N=247)

Predictors B Lower Upper t p<

Neuroticism

Step 1: R2= .11 F= 29.83***

Step 2: R2= .62 F= 198.25***

EPQ-Neu .10 -.19 .40 .68 .497 ns

KIDST .48 .43 .53 18.57 .001***

Psychoticism

Step 1: R2= .07 F= 18.69***

Step 2: R2= .64 F= 215.66***

EPQ-Psy .84 .39 1.29 3.71 .001***

KIDST .46 .42 .51 18.71 .001***

Note: df=246, Significance is presented in the table, *** p<0.001, EPQ-Neu= Eysenck Personality

Questionnaire (Neuroticism sub-scale), EPQ-Psy= Eysenck Personality Questionnaire (Psychoticism sub-

scale), KIDST= Khat Interpersonal Difficulties Scale Total

Figure 2. Simple Mediation Analysis Model for Interpersonal Difficulties as Mediator for

Relationship between Neuroticism and Mental Health Problems (N=247)

Mental Health

Problems

Interpersonal

Difficulties

Neuroticism

97

Figure 3: Simple Mediation Analysis Model for Interpersonal Difficulties as Mediator for the

Relationship between Psychoticism and Mental Health Problems (N=247)

The first model can be conceptualized as a full mediation where the independent variable

(X) has an impact on mediator variable (M), which in turn has an impact on the outcome (Y). On

the other hand, the other model indicated that ID (X) has a direct effect on both (M) and (Y),

which pointing that (M) only increased the impact of (X) on (Y). In the first model, the

interpersonal difficulties fully mediate the relationship between Neuroticism and mental health

problems (R2= .62, F (246) =198.25, p<0.001) as there is no significant direct relationship

between Neuroticism and mental health problems (p<0.4978). However, the other model showed

that interpersonal difficulties partially mediate the relationship between Psychoticism and mental

health problems (R2= .64, F (246) =215.66, p<0.001) as there is a significant direct relationship

between Psychoticism and mental health problems (p<0.001). Regarding the relationship between

mediator (interpersonal difficulties) and predictors (Neuroticism and Psychoticism), significant

relationship was found (R2= .11, F (246) =29.83, p<0.001) and (R2= .07, F (246) =18.69,

p<0.001) respectively.

Interpersonal

Difficulties

Mental Health

Problems

Psychoticism

98

Testing the secondary hypotheses. Khat is chewed with different frequency,

chronicity, and type of Khat. So, the comparison of these differences of patterns of Khat

chewing from personality traits, interpersonal difficulties, and mental health problems are

displayed here. EPQ was used to measure personality traits, KIDS on interpersonal

difficulties, and DASS on mental health problems.

Differences of frequencies of chewing Khat on personality traits,

interpersonal difficulties and mental health problems.

Hypothesis 6: It is hypothesized that the more frequent the individual uses Khat

the more the individual have Psychoticism and Neuroticism personality traits, and

experience interpersonal difficulties and mental health problems.

99

Table 16

One Way Analysis of Variance for Frequency of Chewing Khat the Two Factors (Personal Related and Khat Related) and

Total of KIDS, Three Factors (Depression, Anxiety, and Stress) and Total of DASS, and Four Factors of EPQRS

(Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the Participants (N=247)

Frequency of Chewing Khat

Daily

(n=53)

Four Times a Week

(n=73)

Twice a Week

(n=66)

Once a Week

(n=66)

Variables M SD M SD M SD M SD F p<

Personal Related 25.55 8.74 22.75 11.36 23.55 10.80 21.48 10.02 1.57 .108 ns

Khat Related 20.60 6.34 19.93 8.79 18.91 8.75 17.76 7.07 1.52 .060 ns

KIDS Total 46.15 13.78 42.68 18.99 42.45 18.24 39.24 16.41 1.59 .074 ns

Depression 9.40 3.71 9.05 4.52 8.14 3.74 7.55 4.14 2.89 .018*

Anxiety 9.64 3.62 8.93 4.34 9.56 3.98 8.62 3.84 .97 .410 ns

Stress 10.30 3.40 9.47 4.44 9.09 3.72 8.26 3.72 2.85 .004**

DASS Total 29.34 9.64 26.45 12.28 27.79 10.24 24.42 10.44 2.25 .013*

Extraversion 7.04 2.18 6.52 2.76 6.55 1.95 6.58 1.94 .676 .567 ns

Neuroticism 7.58 2.19 6.82 3.16 6.14 3.09 5.59 2.91 5.271 .003**

Lie scale 5.00 2.37 4.53 2.27 5.83 1.83 5.85 1.89 6.565 .001***

Psychoticism 53 5.08 73 4.48 5.14 1.83 5.27 1.92 2.378 .329 ns

Note: M= mean, SD= Standard deviation, Between group df=3, within group df=254, group total df=257, significant is showed in the table ***p<0.001,

**p<0.01, *p<0.05, KIDS= Khat Interpersonal Difficulties Scale, DASS= Depression, Anxiety, and Stress Scale

100

The table 16 revealed that there were significant differences between frequencies

of chewing Khat on Neuroticism, Depression and Stress, and giving a positive impression

about themselves. The table showed, the more regular the individual chew Khat, the more

Neurotic he/she might be, and experience more Depression and Stress. However, Lie

scale showed that those who chew Khat less frequently gave more impression on

themselves as compared to more frequent users. Finally, in order to avoid obtaining false

positive by running multiple comparison, Bonferroni correction was used.

Differences of chronicity of chewing Khat on personality traits, interpersonal

difficulties and mental health problems.

Hypothesis 7: It is hypothesized that the longer the person chew Khat the more

the person becomes introverted.

101

Table 17

One Way Analysis of Variance for Chronicity of Chewing Khat and the Two Factors (Personal Related and Khat Related) and

Total of KIDS, Three Factors (Depression, Anxiety, and Stress) and Total of DASS, and Four Factors of EPQRS

(Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the Participants (N=247)

Chronicity of Chewing Khat

Less than 1 Year

(n=62)

1-3 Years

(n=83)

4-6 Years

(n=53)

More than 6 Years

(n=60)

Variables M SD M SD M SD M SD F p<

Personal Related 24.29 11.50 23.19 9.35 22.94 9.71 22.33 11.37 .37 .773 ns

Khat Related 18.68 8.17 18.42 7.14 19.57 8.21 20.72 8.43 1.12 .340 ns

KIDS Total 42.97 18.55 41.61 15.42 42.51 17.03 43.05 18.74 .11 .956 ns

Depression 9.11 4.28 8.08 3.96 8.43 3.83 8.40 4.42 .75 .522 ns

Anxiety 9.55 4.25 9.18 3.58 9.13 4.05 8.75 4.21 .41 .747 ns

Stress 9.81 4.25 8.78 3.37 9.02 3.74 9.45 4.41 .92 .432 ns

DASS Total 28.47 11.43 26.05 9.53 26.58 10.78 26.60 12.14 .63 .599 ns

Extraversion 6.66 2.19 7.19 2.34 6.53 1.97 5.98 2.26 3.53 .015**

Neuroticism 6.08 2.97 6.57 3.11 6.91 2.82 6.43 2.94 .76 .517 ns

Lie scale 5.89 1.72 5.23 2.16 4.92 2.47 5.12 2.20 2.27 .081 ns

Psychoticism 5.32 1.91 5.14 1.87 4.83 1.74 4.50 2.10 2.24 .084 ns

Note: M= mean, SD= Standard deviation, Between group df=3, within group df=254, group total df=257, significant of result is displayed in table

**p<0.01, KIDS= Khat Interpersonal Difficulties Scale, DASS= Depression, Anxiety, and Stress Scale

102

The table 17 revealed that there were no significant differences between

chronicity of chewing Khat based on personality traits, interpersonal difficulties, and

mental health problems, except the Extroversion factor. It showed that those students who

were chewing Khat 1-3 years were the ones who were more extroverts and the more the

individual continue chewing Khat the more introverted he will become. To control

obtaining false positive the Bonferroni correction was used.

Differences between students who chew Khat in group or alone on

personality traits, interpersonal difficulties and mental health problems.

Hypothesis 8: It is hypothesized that those students who use Khat alone would have

experience more interpersonal difficulties and mental health problems as compared to

those students who use Khat in-group.

103

Table 18

Means, Standard Deviations, Welch’s t-test and p-values of Pattern of Using Khat (Alone

and In-group) on the Two Factors (Personal Related and Khat Related) and Total of

KIDS, Three Factors (Depression, Anxiety, and Stress) and Total of DASS, and Four

Factors of EPQRS (Extroversion, Neuroticism, Lie Scale, and Psychoticism) of the

Participants (N=247)

Pattern of using khat

Alone

(n=34)

In-group

(n=224)

Variables M SD M SD T p<

Personal Related 26.62 12.36 22.69 10.02 2.06 .081 ns

Khat Related 22.32 10.39 18.79 7.41 2.45 .061 ns

KIDS Total 48.94 21.64 41.47 16.30 2.38 .058 ns

Depression 10.06 4.84 8.24 3.95 2.43 .036*

Anxiety 10.09 4.40 9.02 3.90 1.47 .149 ns

Stress 10.29 4.27 9.07 3.85 1.70 .117 ns

DASS Total 30.44 12.43 26.33 10.54 2.07 .060 ns

Extraversion 6.00 2.28 6.75 2.23 1.81 .092 ns

Neuroticism 6.00 3.14 6.56 2.95 1.03 .311 ns

Lie scale 5.85 1.97 5.21 2.18 1.61 .042*

Psychoticism 5.12 1.74 4.95 1.96 .47 .607 ns

Note: M= mean, SD= Standard deviation, df=256, significant of result is displayed in table *p<0.5, KIDS=

Khat Interpersonal Difficulties Scale, DASS= Depression, Anxiety, and Stress Scale

The table 18 revealed that there were significant differences between those who

chew Khat alone and those who chew Khat with a group based on experiencing

depression and giving positive impression. The individuals who chew Khat alone showed

104

that they experience more depression and show more positive impression then those chew

khat in-group.

105

Section IV: Intervention Study

The result of experiment study was displayed, and the researcher started to

demonstrate the characteristics of participants and then compared the treatment group to

the control group. Both groups were tested twice, before the experiment and after the

experiment. To display the demographic characteristics, the researcher used frequency

and percentage. For comparing the two groups the researcher employed t-test to find out

the differences between the two group on interpersonal difficulties and mental health

problems, and Chi-squared to compare the two group on the pattern of Khat chewing

behavior.

Table 19

Means, and Standard Deviations of Age of the Participants CBT Group (n=20), PET

Group (n=20)

Variables

CBT Group PET Group

M SD M SD

Age in Years 22.15 2.32 22.30 2.20

Note: M= mean, SD= Standard deviation, CBT= Cognitive Behavioral Therapy, PET=

Psycho-Educational Therapy

The above table shows that the two group have similar ages with nearly equal

mean and standard deviation.

106

Table 20

Frequencies and Percentage of Patterns of Khat Chewing between CBT Group and PET

Group in Experiment Study of the Participants (N=40)

CBT Group

(n=20)

PET Group

(n=20)

Total

Variables f(%) f(%) f (%)

Groups 20 (50) 20 (50.00) 40 (100)

Levels of Education

BS-I 3 (15) 6 (30.00) 9 (22.50)

BS-II 5 (25) 2 (10.00) 7 (17.50)

BS-III 8 (40) 5 (25.00) 13 (32.50)

BS-IV 4 (20) 7 (35.00) 11 (27.5)

Frequency of Chewing Khat

Daily 6 (30.00) 11 (55.00) 17 (42.50)

Four Times a Week 7 (35.00) 2 (10.00) 9 (22.50)

Twice a Week 3 (15.00) 1 (5.00) 4 (10.00)

Once a Week 4 (20.00) 6 (30.00) 10 (25.00)

Chronicity of Chewing Khat

Less than 1 year 5 (25.00) 3 (15.00) 8 (20.00)

1-3 years 5 (25.00) 5 (25.00) 10 (25.00)

4-6 years 3 (15.00) 7 (35.00) 10 (25.00)

More than 6 years 7 (35.00) 5 (25.00) 12 (30.00)

Hours of Chewing Khat per

Day

1-4 hours 5 (25.00) 3 (15.00) 8 (20.00)

5-8 hours 4 (20.00) 5 (25.00) 9 (22.50)

More than 8 hours 11 (55.00) 12 (60.00) 23 (57.50)

Type of Khat Chewed

Daba Musbar 2 (10.00) 3 (15.00) 5 (12.50)

Jabis 13 (65.00) 8 (40.00) 21 (52.50)

107

Dadar 1 (5.00) 4 (20.00) 5 (12.50)

Boondaro 0 (0.00) 3 (15.00) 3 (7.50)

Others 4 (20.00) 2 (10.00) 6 (15.00)

Note: f=frequency, %= percentage, CBT= Cognitive Behavioral Therapy, PET= Psycho-

Educational Therapy

Table 20 describes the frequency and percentage of the demographic

characteristics of the sample consists of 20 CBT group and 20 PET group. Both group

had approximately equal proportion of levels of university, frequency of chewing Khat,

chronicity, duration of session of chewing Khat, and type of Khat chewed. This is

showed that the two groups were comparable and only differ the manipulation that each

group received.

Hypothesis: It is hypothesized that those Khat user students who receive 7

sessions of CBT would significantly decrease interpersonal difficulties and mental health

problems as compared those Khat user students who receive psycho-education.

In order to test this hypothesis, the researcher used t-test to compare the treatment

group to control group on interpersonal difficulties and mental health problems.

108

Table 21

Means, Standard Deviations, t and p-values for Comparing CBT Group and PET Group

on the Basis of Khat Interpersonal Difficulties and Mental Health Problems of the

Participants (N=40)

Groups

CBT

(n=20)

PET

(n=20)

Variables M SD M SD t p<

Pretest KIDS Total 49.250 11.49 57.85 13.68 2.15 .102

DASS Total 32.50 5.71 35.80 6.70 1.68 .038*

Posttest KIDS Total 32.80 13.57 56.85 13.95 5.53 .001***

DASS Total 18.05 9.57 32.10 6.74 5.37 .001***

Note: df=38, significance in the table is shown ***p<0.001, *p<0.05, M= mean, SD=

Standard deviation, KIDS= Khat Interpersonal Difficulties Scale, DASS= Depression,

Anxiety, Stress Scale, CBT= Cognitive Behavioral Therapy, PET= Psycho-Educational

Therapy

Figure 4: Differences of CBT group and PET group based upon mental health problems

before and after the therapy (N=40)

109

Figure 5: Differences of CBT group and PET group based upon interpersonal difficulties

before and after the therapy (N=40)

Table 21 and figure 4 and 5 displayed that there were highly significant

differences between the CBT group and the PET group after each group received their

perspective therapy. It showed that the interpersonal +difficulties and mental health

problems that experienced by the CBT group had significantly decreased after received

cognitive behavior therapy. Moreover, the table indicated that the two groups had mild,

significant differences in mental health problems before the therapies administered.

However, the PET showed similar results at the posttest while the CBT group had

drastically changed.

Hypothesis: It is hypothesized that those Khat user students who receive 7

sessions of CBT would significantly reduce Khat chewing behaviors as compare to those

Khat user students who receive PET.

In order to test this hypothesis, it was carried out Chi-Square test to find out the

difference between CBT group and PET group on the basis of patters of chewing Khat.

110

Table 22

Chi-Square Comparison between CBT Group and PET Group on the Basis of Patterns of

Khat Chewing after Received Treatment

Group

CBT PET

Variables f(%) f(%) χ2 p<

Frequency of Chewing Khat

Daily 1 (5.00) 11 (55.00) 13.91 .003**

Four times a Week 1 (5.00) 2 (10.00)

Twice a Week 5 (25.00) 1 (5.00)

Once a Week 13 (65.00) 6 (30.00)

Hours of Chewing Khat per

Day

1-4 hours 9 (45.00) 3 (15.00) 7.86 .020*

5-8 hours 8 (40.00) 6 (30.00)

More than 8 hours 3 (15.00) 11 (55.00)

Type of Khat Chewed

Daba Musbar 3 (15.00) 2 (10.00) 4.67 .323 ns

Jabis 14 (70.00) 10 (50.00)

Dadar 1 (5.00) 4 (20.00)

Boondaro 0 (0.00) 2 (10.00)

Others 2 (10.00) 2 (10.00)

Note: f= frequency, % = percentage, Frequency df=3, hours spend df=2, type of khat

df=4, significance of result in the table is shown **p<0.001, *p<0.05, χ2=chi square,

CBT= Cognitive Behavioral Therapy, PET= Psycho-Educational Therapy

Table 22 indicated that the CBT group had significantly decreased the frequency

and length of a session of chewing khat after received seven sessions of cognitive

behavioral therapy. Contrary, the PET group showed an approximately similar result for

both pretest and posttest. Regarding the types of Khat chewed it stays almost the same for

111

pretest and posttest in both groups, and it is because to change the preferred type of Khat

takes time, same as the other preferred things.

112

Summary of Results

The present study combines four sub-studies that include Scale Development,

Prevalence Study, Cross-Sectional Study, and Experimental Study. Their sample sizes

were as follows: the scale development 200 participants, prevalence study 1153

participants, cross-sectional 350 participants, and experiment study 40 participants. The

sample was divided equally between the four levels of undergraduate university students

with the aged rage between 18-25 years. The first study was involved the development of

Khat Interpersonal Difficult Scale (KIDS) which had two factors (Personal related and

Khat related). With regard to personality measurement, it was used Eysenck Personality

Questionnaire (EPQ) which consisted of four factors (extroversion, neuroticism, Lie

scale, and psychoticism), while mental health problems were calculated on Depression

Anxiety Stress Scale (DASS).

The main objectives of the study were to find the prevalence of Khat chewers

among university students, differences between Khat users and non-users on personality

traits, interpersonal difficulties, and mental health problems, as well as, to find out the

effectiveness of CBT on Khat addiction. Starting with the prevalence study, the result

revealed that, nearly 17% of Amoud university students were currently Khat chewers,

while around 30% were life time prevalence of Khat users. Having father who chews

Khat, having siblings who chew Khat, having friends who chew Khat, having ever

smoked cigarettes all are associated with life time prevalence of Khat chewing (p<0.001).

In addition, it was found students who use Khat score high on neuroticism (p<0.001) and

psychoticism (p<0.01), and at same time experience more interpersonal difficulties and

mental health problems (p<0.001) as compared to those students who don’t use Khat. The

study determined as well a strong relationship between personality traits (neuroticism and

113

psychoticism) with interpersonal difficulties and mental health problems (p<0.001).

Finally, the experiment study showed that after administration of CBT to treatment group

there was significant decrease on Khat chewing behaviors, interpersonal difficulties, and

mental health problems, as compared to control group who receive psycho-education.

Moreover, the secondary objectives were to find the differences between years of

university and differences of patterns of Khat chewing on the basis of personality traits

interpersonal difficulties, and mental health problems. It was found that year four of

undergraduate students experience more neuroticism as compared to other years of the

university. However, there were no differences found between years of university on the

basis of other personality types, interpersonal difficulties, and mental health problems. It

was found as well the daily Khat users experience more depression (p<0.05), more stress

(p<0.05), more neuroticism as compared to once a week, twice a week, and four times a

week of chewing Khat. Moreover, once a week uses more lie than other frequencies of

chewing Khat (p<0.001). Regarding chronicity of chewing Khat, it was identified those

students who chewed Khat 1-3 years were more extroverted than those used Khat less

than 1 year, 5-6 years, or more than 6 years (p<0.01). There were no differences on

chronicity of Khat chewing on other personality traits (neuroticism and psychoticism),

interpersonal difficulties, and mental health problems. Finally, those students who chew

Khat alone experience more interpersonal difficulties by scoring high on both personal

related (p<0.05), and Khat related (p<0.05), as well as depression (p<0.05), as compared

to the students who chew Khat in-group.

114

Chapter V

Discussion

The objectives of the current study are to find the prevalence of chewing Khat

among university students; compare Khat users and non-Khat users on personality traits,

interpersonal difficulties, and mental health problems; and find efficacy of CBT on Khat

addiction. In order to fulfill these objectives, the Khat Interpersonal Difficulties Scale

(KIDS) was developed, which is valid to Somali culture. The common interpersonal

problems as experienced by Khat Addicts were combined and made in to a 4- point self-

report scale (KIDS). Factor analysis of 33 items indicated two factor solutions that named

on: Personal Related and Khat Related. The personal related factors discussed that Khat

addict’s individuals expressed negative views about themselves. This is because the

behaviors that are associated with Khat use are mostly contrary to the norms of the

society they live in. So, the individual is seeing himself doing something that his family

and society at large don’t approve of and can possibly be criticized for. According to

Luoma and Platt (2015) society take an essential role in the development of self-criticism

and shame by devaluating and forming stigmatized identities. Shame is the emotion that

indicates the experience of stigma and has a tendency to include a combination of

convictions of being defective or unlovable. More to that shame is the main components

of stigma, blocks social commitment, advances relational detachment, and meddles with

relational problem-solving.

Furthermore, most Khat users (especially young people) spend more time on

acquiring and using Khat, which in turn creates difficulties for them in fulfilling their

responsibilities. Additionally, the Khat chewers individuals find themselves in financial

115

troubles, which often make them turn to illegal means to acquire the resources they need

to fuel their addictions. Stealing cash, credit cards, or identities from those they

purportedly love, are just some of the crimes that can be committed on family and friends

by an addicted person who is facing financial difficulties. All these factors contribute to

leading the individuals to see themselves as inferior to others. The emotions are

exacerbated by the fact that the Somali culture is collectivistic, in which the individuals

interrelated and need to each other (Luoma, Kohlenberg, Hayes, & Fletcher, 2012).

Khat related factors address the way Khat related behaviors effect one’s

relationships with others. As the individual is busy with Khat most of the time, he or she

does not have time to communicate with people other than the Khat users. An altered

sleep-wake cycle, the degree of use, and the isolating nature of locations where Khat is

chewed also become a barrier to the interaction with non-Khat users (Omar et al., 2015).

Khat use is similar to internet addiction in the way that both types of addicts spend most

of their time on their addictions, which increases difficulties of individuals in relating to

other people. Numerous researches suggests that internet addiction effects interpersonal

relationships (Leung & Lee, 2012; Milani, Osualdella, & Blassio, 2009; Scherer, 1997;

Seo, Kang, & Yom, 2009; Young, 1998) as internet use had interfered with addict’s daily

activities, professional performance or social lives. All studies have indicated that

excessive use of the internet has negative consequences on personal, family, and work

lives.

Regarding the prevalence study of Khat chewing among the students, it was found

similar results on many prevalence that takes place in a neighboring country Ethiopia.

Because of no prevalence study in Somalia for the past decades, it was used to compare

116

the prevalence of neighboring country. The student’s lifetime prevalence was 29.4%,

which was comparatively similar to 33% among students of Bahir Dar University,

Ethiopia (Baynesagne, Ayele, & Weldegerima, 2009) and 31.9% among students of

pharmacy and technology at Addis Ababa University Ethiopia (Eshetu & Gedif, 2006).

On the other hand, the students that currently consume Khat were observed to be 17%

which was equivalent to 12.7% among students of Bahir Dar College Ethiopia

(Gebrehanna, Berhane, & Worku, 2014).

Moreover, variables such as having a father or friend or siblings who chews Khat,

or being ever smoked cigarettes contributes the chances to use Khat. Fatherly substance

use as general has been appeared to be related with higher chances of substance use

among students in secondary schools (Dida, Kassa, Sirak, Zerga, & Dessalegn, 2014;

Johnson & Pandina, 1991). Similarly, past researches have additionally indicated that

adolescent or young adult’s alcohol abuse is to be linked with paternal alcohol abuse

(Lieb et al., 2002; Van Der Vorst, Vermulst, Meeus, Deković, & Engels, 2009). This

appears that youngsters are following the footsteps of their fathers. Having friend or

friends who chew Khat has also linked for an increase of chewing Khat which is

additionally reliable with past investigations which announced higher chances of Khat

using among students who had Khat chewing friends (Deressa & Azazh, 2011;

Gebreslassie, Feleke, & Melese, 2013). Peer influence is well-known perspective for

addiction, in which having friend who dependent to any substance make the individual to

be vulnerable to start that substance. This affiliation can be seen from two points of view.

From one perspective, students who were not Khat chewers could start chewing Khat,

because of their Khat user friends. In another perspective, being chewing Khat can be the

117

reason behind having friendship with Khat user for the first place, because students prefer

to have a company with other students who had similar Khat use status. Studies have

demonstrated the propensity of young people's inclination to become close friends with

companions who are like them as far as marijuana use (De La Haye, Green, Pollard,

Kennedy, & Tucker, 2015) and alcohol use (Osgood et al., 2013).

Cigarette smoking is additionally observed to be fundamentally connected with

Khat using. This finding is in agreement with past researches (Deressa & Azazh, 2011;

Gebreslassie et al., 2013) which revealed higher chances of chewing Khat with the

participants who smoke a cigarette. Kassim, Rogers, and Leach (2014) have shown that

cigarette smoking initiate chewing Khat up to 45% those uses Khat. Thus, as smoking

could be a passage point to the Khat chewing propensity, the turn-around could likewise

be true. It can be that Khat is the gateway of other addictions in Somali context, which

people especially youngsters start chewing Khat first and then Smoking. Finally, the peak

age of chewing Khat in this study was observed to be somewhere in the range of 21 and

25 years, which was similar to other studies such as college students in Bahir Dar town

and furthermore among high school and college students in Jazan, Kingdom of Saudi

Arabia (Al-Sanosy, 2009; Odenwald et al., 2005; Widmann et al., 2014).

The present study distinguished that those students who consume Khat scored

high on Neuroticism and Psychoticism when contrasted with those students who don't

consume Khat. However, non-Khat chewers scored high on the Lies scale and there were

no significant differences on Extraversion between the two groups. It was found as well

that students who use Khat experienced more interpersonal difficulties and mental health

problems as compared to the control group. Lastly the study determined a strong positive

118

relationship between personality traits (neuroticism and psychoticism) with interpersonal

difficulties and mental health problems.

Starting with the differences of personality traits between Khat users and non-khat

users, in which Khat users were scored high on Neuroticism and Psychoticism, while

scored low on Extroversion and Lie scale. Many studies support the relationship between

the three Eysenck personality traits and addiction. Sahasi, Chawla, Bhushan, and Kacker

(1990) discovered heroin addicts scored high on Psychoticism, Neuroticism and Lie scale

and low on Extroversion as compared with normal controls. This is similar to the findings

of (Blaszczynski et al., 1985; Gossop & Eysenck, 1983). Moreover, Spielberger and

Jacobs (1982) studied the connection between personality traits and the starting or

maintaining smoking habit. They discover smoker had high score on Neuroticism,

Psychoticism, and Extraversion, and low score on the Lie Scale as compared to non-

smokers. They came to conclusion that starting and maintaining smoking is impacted by

different personality traits. Although the Lie Scale was initially designed to measure the

tendency to dissimulate ("fake good"), some research suggests that low scores on this

scale may be associated with nonconforming and rebellious' attitudes (Eysenck, 1980).

However, it can be seen a contradiction of the above research, for that heroin addict had a

high score on lie scale while smokers had a low score. This contradiction shows that

different substance abuse creates a different attitude for the individual who is dependent

on them. For instance, Smith's (1970) found that smoking was associated with antisocial

tendencies in 17 of 19 studies.

Regarding interpersonal difficulties, the study found that students who chew Khat

experience more interpersonal difficulties than the non-Khat users. Around 30% to 40%

119

of alcoholics seem to live alone, and the same number of as half live disconnected from

their relatives. Old men with heavy-drinking problems were found to be likely live in

isolation, contact less with their family and friends, and less take part in all kind of social

activities (Strug & Hyman, 1981). High scores on the Drug Abuse Screening Test

(DAST) were positively identified to be associated with interpersonal problems (Skinner,

1982). It is believed that individuals with interpersonal difficulties had insecure

attachment to their caregivers during childhood. They develop an insecure attachment to

their significant figure which manifests in adulthood as having challenges relating to

other people. Insecure attachment means the person experiences high rejection

sensitivity, lower self-esteem, and negative view of self and others. As the individual

feels the pain of isolation, it directly effects the motivation to use drugs or alcohol in

order to relieve tension and to establish a bond with the drug (Leach & Kranzler, 2013).

The present study discovered as well that Khat users have more mental health

problems than non-khat users. Many studies support the notion that substance abuse is

associated with negative effects including anxiety, depression, and stress (Ahmadi &

Ahmadi, 2005; Ahmadi, Toobaee, Kharras, & Radmehr 2003; Goeders 2004; Roberts

2000). Self-medication hypothesis believes that action of every drug of abuse is to

decrease the adverse and painful effects, and the individual is picking the substance to

deal with an unpleasant emotional state. In other words, those individuals who are

suffering psychological problems are more vulnerable to use drugs to copy the negative

effect (Khantzian, 1997).

The present study also found a strong relationship between having Neuroticism and

Psychoticism personality traits and experiencing interpersonal difficulties and mental

120

health problems. Many researchers found similar results (Costa & McCrae, 1992;

Gurtman, 1995; Nysæter et al., 2009). Neuroticism had a strong link to interpersonal

difficulties. The individuals who scored high on both Neuroticism and Psychoticism are

altogether more prone to report having relationship issues (McDonald & Linden, 2003).

Clark, Watson, and Mineka (1994) believed that Neuroticism is also associated with all

anxiety and depression disorders. Moreover, people with a high score on Psychoticism

experience with negative emotions and behavior patterns such as depression, anxiety,

anger, and so on (Ying Ge & Zhang, 2015). On the other hand, the study discovered that

interpersonal difficulties mediate fully or partially for the relationship between

personality traits and interpersonal difficulties. According Differential Exposure-

Reactivity Model (Bolger & Schilling, 1991), personality affects both a person’s

exposure to stressful events, as well as their reactivity to those events. Thus, being high in

neuroticism or psychoticism tend to increase for the individual to perceive more stress in

their environment (such as relationship to other people), and at the same time can

overreact to the situations, and in a combination or interaction of these two factors could

lead to the development of mental health problems.

The study also found that Extroversion is associated with mental health problems.

Like alcohol, Khat is a social habit which people mostly use in a group. Some research

links extraversion to problematic drinking patterns (Fairbairn et al., 2015). Researchers

have long hypothesized that such associations are attributable to increased alcohol-reward

sensitivity among extraverted individuals, and surveys suggest that individuals high in

extraversion gain greater mood enhancement from alcohol than those low in extraversion

(Sher & Wood, 2005). Similarly, the more the individual use Khat, the more the mental

121

health problems he experiences (Odenwald, & Al'Absi, 2017). It was found as well that

using Khat for long sessions per-day and chewing the intense type of Khat is linked to

have more interpersonal problems. As the individual is occupied with Khat more often

than not, he doesn't have time to contact with individuals other than Khat users. An

altered sleep-wake cycle, the level of utilization, and the isolation of the locations where

khat is chewed, contributes for the individual to have difficulties interacting with other

people (Omar et al., 2015). Moreover, the more intense the type of Khat the individual

uses the more mental health problems he experiences.

Furthermore, the study associated more frequent use of Khat into Neuroticism,

Depression, Stress, and giving a less positive impression about one’ self. It showed, the

more regular the individual chew Khat, the more Neurotic he/she might be, and

experience more Depression and Stress. Researches documented well substance abuse

effect mental health problems and the more the person abuse the substance, the more

mental health problems he/she experienced. According to toxicity hypothesis, mental

health problems are the result intemperate substance abuse (Colizzi & Murray, 2018;

Quello, Brady, & Sonne, 2005). However, Lie Scale showed that those who chew Khat

less frequently gave more impression on themselves as compared to more frequent users,

which indicates the more frequent chewers had less time to give a positive impression to

themselves as they are preoccupied with the habit of chewing Khat. It is also pointing out

that the more frequent users have fewer chances to hide the habit of Khat chewing and

the consequences that followed.

Concerning chronicity of Khat chewing, the study found that Khat uses initially

increase to be extroverted, but as the time passes, the graph goes toward the introversion.

122

The study indicated, those students who were chewing Khat 1-3 years were the ones who

were more extroverts and the more the individual continue chewing Khat, the more

introverted he will become, because the habit of chewing Khat makes the individual more

social at the beginning, but as the time goes the person’s social circle goes to decrease.

This is in the line of the hypothesis that believes drugs suppress extroversion (Spotts &

Shontz, 1984). The study indicated as well, those individuals who chew Khat alone,

experience more interpersonal difficulties and mental health problems as compared to

those who chew in-group. Khat is a social habit (Stevenson, Fitzgerald, & Banwell,

1996), which most of the chewers prefer to consume with groups, as they get help and

share their grieves. However, those who chew Khat alone, cannot get group benefits

which make them vulnerable to experience mental health problems. Moreover, it can be

that interpersonal difficulty they experience made them have a limited social experience.

Finally, the experiment study showed that after administration of CBT to

treatment group there was significant decrease on Khat chewing behaviors, interpersonal

difficulties, and mental health problems, as compared to control group who receive

psycho-education. Kaminer, Burleson, and Goldberger (2002) used to compare the

effectiveness of psychoeducation to the efficacy of cognitive behavior therapy (CBT) on

dealing with adolescent substance abuse. 88 adolescents with a dual diagnosis from

outpatient were randomly assigned with either receiving eight weeks of CBT or

Psychoeducation. Outcome measurement was used for drug urinalysis and the Teen-

Addiction Severity Index (T-ASI). CBT subjects showed altogether bring down rates of

positive urinalysis than psychoeducation subjects and across the conditions for older

youth and male subjects at 3-month follow-up assessment. Most T-ASI subscales

123

demonstrated change from baseline to 3-and 9-month follow-up assessment for both

conditions. The decrease in substance utilization was accomplished paying little mind to

treatment conditions.

Moreover, the post treatment measurement was showed that the mental health

problems were improved significantly for the CBT group. The decreasing of Khat

consumption time enhances everyday functioning and improves the sleeping routing,

which later increment the individual's physical and emotional well-being by the decline

of the impact of Khat and the expansion of self-improvement. Accordingly, the increase

in mental health and everyday functioning enables Khat users to concentrate more on

employment and other day-to-day activities which serve as prevention for further

development of Khat chewing behavior (Widmann et al., 2017). There are some

hypotheses for the direction of co-occurrence between substance abuse and mental

illnesses. One of these explanations is the self-medication hypothesis which infers that

people will in general select drugs that lighten their particular symptoms of mental

illnesses. For instance, a few analysts propose that individuals with wild sentiments of

anger and animosity may pick opiates for these drugs' progressing impacts, while

individuals who are depressed may take cocaine since it thrills and stimulates them

(Sarvet et al., 2018). Experiencing depression and PTSD appears to have effect with

regards to treatment outcome, for example decrease of khat use. Among the people with

depression and PTSD the burden of symptoms of mental illnesses are heavier and using

Khat enhances mood and destructs from the painful experience (Widmann et al., 2017).

Another explanation is the toxicity hypothesis which believes that mental health

problems are the result of the excessive use of drugs, which either directly link like

124

cannabis for psychosis (Colizzi et al., 2018) or precipitate and exacerbate the course of

the disorder (Quello et al., 2005). When it comes for chewing Khat, it is linked to the

rising of mental illnesses in Somalia. Both explanations are applicable for the relationship

of Khat chewing behavior and mental health problems, and it seems that every day

functioning is the mediator which is suggested for the future studies to take into account

(Widmann et al., 2017).

Implications of the Studies

The US National Institute of Drug Abuse (Robertson, David, & Rao, 2003)

highlighted the research areas needed to be covered in order to prevent any drug of abuse.

Some of these areas are to find risk factors, magnitude and effective intervention of

particular substance abuse. It also proposed to develop ecological valid psychometrically-

sound measures, instruments and data collection procedures to assess the drug of abuse.

The use of khat, has been largely neglected by public health and addiction scientists for

decades (Gowing et al., 2015). PubMed lists a total of 564 papers whose title or abstract

contain the word ‘khat’, compared with more than 800 000 for ‘alcohol’. For that reason,

the present protocol in compassed for different studies that focus on four different area of

research that include developing Khat Interpersonal Difficulties Scale (KIDS);

prevalence of chewing Khat among university students; comparing Khat users with non-

Khat users on the basis of personality traits, interpersonal difficulties and mental health

problems; and finding efficacy of CBT on Khat use.

One of the contributions of these studies was the development of a valid and

reliable assessment tool with high ecological that has been related to interpersonal

difficulties experienced by Khat users. The Khat Interpersonal Difficulties Scale (KIDS)

125

consisted of two factors (Khat related and Person related) and was found to be similar

with the other theories of interpersonal difficulties such as contemporary interpersonal

and attachment theory. The contemporary interpersonal theory is made up two

dimensions that named agency (social dominance) and communion (nurturance) that are

the basis of interpersonal behavior. Also, attachment theory shares similar dimensions’

attachment anxiety ‘‘fear of rejection’’ that is linked to relatedness dimension, and

attachment avoidance ‘‘discomfort with closeness’’ is conceptually linked to the self-

definitional dimension. Likewise, the items of the first factor of this scale portraits

because of giving more time on acquiring and using Khat, the individual cannot have

time to interact with other people, while the items of the second factor shows the

individual to have poor opinion about him/herself which resulted to have difficulties

related with other people. This scale will help the researchers to collect data from Khat

users and the counselors to assess and find the area of interpersonal difficulties of the

individuals using Khat.

The study also compared Khat users with non-Khat users on personality traits,

interpersonal difficulties, and mental health problems, and found similar results with the

previous research on other addictions. So far there is no research of this nature on people

who chew Khat, however, there are numerous studies on this area with other substance

use. Finding similar results with other substance use will help with the management plan,

public awareness, and policy of other substance use to be applied to Khat use. Having

ascertained the magnitude of the problems and identifying the specific areas of

dysfunction, will help for developing for counselling and rehabilitation for those who

addict khat. These counseling and guidance programmes would focus on providing

126

psychological help to reduce dependency of Khat, and the interpersonal difficulties and

mental health problems related to Khat.

Finally, intervention study was also carried out which was assessed the efficacy of

CBT for Khat use. It was found that CBT is effective for reducing dependency of

chewing Khat and reducing the problems related to Khat use. The therapy incorporated a

wide range of behavioral therapy including those focusing on operant learning forms and

other cognitive-behavioral interventions. Despite the heterogeneity of Khat use, the core

elements were characterized by learning process of Khat use and the consequences of

interpersonal and mental health problems. High-risk situations are distinguished as

people or place and found as well the consequences of chewing Khat. Cognitive behavior

therapy can be used to deal with risk situations and coping consequences after chewed

khat.

Limitations and Suggestions

The limitations of the study and the suggestions for future research are described

as follows:

The participants of the study were undergraduate university students, so it has a

less generalizable for society at large. Hence, similar studies can be carried out in

school children, employees, illiterate people, administrators, and so on.

The study was conducted in an urban area, and it is less applicable for rural areas

as the circumstances are different. Equally, it will be useful to have a study that

was solely conducted in a rural area.

As this study has taken into account only male Khat users, a similar study can be

carried out on female Khat chewers alone or comparing with male Khat chewers.

127

The prevalence study was only taken from university students, so that it is

important to have a large epidemiological study on general populations.

The Khat users were recruited through snow ball sampling and future researches

need to use random sampling techniques in order to improve generalibility.

The sample size of Khat users and non-Khat users were not equal, so that future

researches are suggested to take equal sample for both Khat users and non-Khat

users.

The measures used in intervention study are assisted self-reports for assessing

khat use amount and frequency instead of gold standard clinical interviews or

objective biological measures data such as blood or urine samples. To my

knowledge there are currently no such objective tools available, to measure khat

alkaloids under field conditions.

Conclusion

The present studies were carried out to find some of the problems related to Khat

use and to assess the effectiveness of CBT on Khat chewing behavior. To do that, Khat

interpersonal difficulties scale (KIDS) with two factors (Khat related: interpersonal

difficulties that resulted from acquiring or using Khat, and person related: interpersonal

difficulties that resulted from negative view about self-due to the habit of chewing Khat

which is contrary to norms of the society) was developed. In addition, prevalence of

chewing Khat in university students were conducted; a comparison of Khat users and

non-Khat users on the basis of personality traits, interpersonal difficulties, and mental

health problems taken place; and lastly, finding the efficacy of CBT on Khat using

behavior were assessed. Starting with the prevalence study, nearly 17% of Amoud

128

university students were currently Khat chewers, while around 30% were life time

prevalence of Khat users. Having a father who chews Khat, having siblings who chew

Khat, having friends who chew Khat, having ever smoked cigarettes all are associated

with life time prevalence of Khat chewing.

Regarding the comparison study, it was found that students who use Khat score

high on neuroticism and psychoticism, and at same time experience more interpersonal

difficulties and mental health problems, as compared to those students who don’t use

Khat. The study determined as well a strong relationship between personality traits

(neuroticism and psychoticism) with interpersonal difficulties and mental health

problems. Finally, the intervention study showed that after administration of 7 sessions of

CBT to the treatment group, there was significant decrease on Khat chewing behaviors,

interpersonal difficulties, and mental health problems, as compared to control group who

receive psycho-education only.

129

References

Abbink, J. (1992). Ch'at in popular culture, a 'prayer' from Harär, Ethiopia. Sociology

Ethnology Bulletin, 1(2), 89-93.

Abbott, P. J. (1996). American Indian and Alaska native aboriginal use of alcohol in the

United States. American Indian and Alaska Native Mental Health Research, 7(2), 1-

13. doi: 10.5820/aian.0702.1996.1

Abbott, P., & Chase, D. M. (2008). Culture and substance abuse: Impact of culture

affects approach to treatment. Psychiatric Times, 25(1), 43-46.

Abu-Arab, M., &Hashem, E. (1995). Some personality correlates in a group of drug

addicts. Personality and Individual Differences, 19(5), 649-653.

doi.org/10.1016/0191-8869(95)00115-M

Aden, A., Dimba, E. A. O., Ndolo, U. M., & Chindia, M. L. (2006). Socio-economic

effects of khat chewing in north eastern Kenya. East African Medical Journal, 83(3),

69-74. doi: 10.4314/eamj.v83i3.9400

Adorjan, K., Odenwald, M., Widmann, M., Tesfaye, M., Tessema, F., Toennes, S., ...&

Rockstroh, B. (2017). Khat use and occurrence of psychotic symptoms in the general

male population in Southwestern Ethiopia: Evidence for sensitization by traumatic

experiences. World Psychiatry, 16(3), 323-323. doi: 10.1002/wps.20470

Ageely, H. M. (2008). Health and socio-economic hazards associated with khat

consumption. Journal of Family & Community Medicine, 15(1), 3-11.

Ahmadi, J., Toobaee, S., Kharras, M., & Radmehr, M. (2003). Psychiatric disorders in

opioid dependants. International Journal of Social Psychiatry, 49(3), 185-191. doi:

10.1177/00207640030493004

130

Ahmadi, M., & Ahmadi, J. (2005). Substance-induced anxiety disorder in opioid

dependents. Addictive Disorders & Their Treatment, 4(4), 157-159. doi:

10.1097/01.adt.0000163699.83614.25

Aiken, L.R. (1989). Assessment of personality. Needham Heights, US: Allyn & Bacon

Al'Absi, M., Khalil, N. S., Al Habori, M., Hoffman, R., Fujiwara, K., & Wittmers, L.

(2013). Effects of chronic khat use on cardiovascular, adrenocortical, and

psychological responses to stress in men and women. The American Journal on

Addictions, 22(2), 99-107. doi: 10.1111/j.1521-0391.2013.00302.x.

Alem, A., Kebede, D., & Kullgren, G. (1999). The prevalence and socio‐demographic

correlates of khat chewing in Butajira, Ethiopia. Acta Psychiatrica

Scandinavica, 100 (S397), 48-55. doi: 10.1111/j.1600-0447.1999.tb10699.x

Al‐Hebshi, N., & Skaug, N. (2005). Khat (Catha edulis)—an updated review. Addiction

Biology,10(4), 299-307. doi: 10.1080/13556210500353020

Ali, A. A., Al‐Sharabi, A. K., Aguirre, J. M., & Nahas, R. (2004). A study of 342 oral

keratotic white lesions induced by qat chewing among 2500 Yemeni. Journal of Oral

Pathology & Medicine, 33(6), 368-372. doi: 10.1111/j.1600-0714.2004.00145.x

Allen, J. P., Chango, J., Szwedo, D., Schad, M., & Marston, E. (2012). Predictors of

susceptibility to peer influence regarding substance use in adolescence. Child

Development, 83(1), 337-350. doi: 10.1111/j.1467-8624.2011.01682.x.

Al-Motarreb, A., Al-Habori, M., & Broadley, K. J. (2010). Khat chewing, cardiovascular

diseases and other internal medical problems: The current situation and directions for

future research. Journal of Ethnopharmacology, 132(3), 540-548. doi:

10.1016/j.jep.2010.07.001.

131

Al-Motarreb, A., Al-Kebsi, M., Al-Adhi, B., & Broadley, K. J. (2002). Khat chewing and

acute myocardial infarction. Heart, 87(3), 279-280. doi: 10.1136/heart.87.3.279

Al‐Motarreb, A., Baker, K., & Broadley, K. J. (2002). Khat: Pharmacological and

medical aspects and its social use in Yemen. Phytotherapy Research, 16(5), 403-413.

doi: 10.1002/ptr.1106

Al-Sanosy, R. M. (2009). Pattern of khat abuse and academic performance among

secondary school and college students in Jazan region, Kingdom of Saudi Arabia

(KSA). Journal of Family & Community Medicine, 16(3), 89-95.

Alsanosy, R. M., Mahfouz, M. S., & Gaffar, A. M. (2013). Khat chewing habit among

school students of Jazan region, Saudi Arabia. Plos One, 8(6), 1-7. doi:

10.1371/journal.pone.0065504

Amirabadi, B., Alibeigi, N., Nikbakht, M., Massah, O., Farhoudian, A., & Doostian, Y.

(2015). Personality traits and psychopathology in nicotine and opiate dependents

using the gateway drug theory. Iranian Rehabilitation Journal, 13(1), 60-56.

Anderson, D., Beckerleg, S., Hailu, D., & Klein, A. (2007). The khat controversy:

Stimulating the debate on drugs. Oxford, UK: Berg Publisher.

Anderson, D.M., Carrier, N. (2006). Flowers of paradise, or polluting the Nation?

Contested Narratives of Khat Consumption. In J. Brewer, F. Trentmann, (Eds.),

Consuming cultures, global perspectives: Historical trajectories transnational

exchanges (pp. 145-166). Oxford, Berg: Bloomsbury Publisher.

Arce-Ferrer, A. J., & Ketterer, J. J. (2003). The effect of scale tailoring for cross-cultural

application on scale reliability and construct validity. Educational and Psychological

Measurement, 63(3), 484-501. doi: 10.1177/0013164403063003009

132

Arria, A. M., & DuPont, R. L. (2010). Nonmedical prescription stimulant use among

college students: Why we need to do something and what we need to do. Journal of

Addictive Diseases, 29(4), 417-426. doi: 10.1080/10550887.2010.509273

Arthur, M.W., Hawkins, D.J., Pollard, J.A., Catalon, R.F., & Baglioni, A.J. (2002).

Measuring risk and protective factors for substance use, delinquency, and other

adolescent problem behaviours. Evaluation Review, 26(6), 575-601. doi:

10.1177/0193841X0202600601

Awas, M., Kebede, D., & Alem, A. (1999). Major mental disorders in Butajira, southern

Ethiopia. Acta Psychiatrica Scandinavica, 100(397), 56-64. DOI: 10.1111/j.1600-

0447.1999.tb10695.x

Ayana, A. M., & Mekonen, Z. (2004). Khat (Catha edulis Forsk) chewing,

sociodemographic description and its effect on academic performance, Jimma

University students 2002. Ethiopian Medical Journal, 42(2), 125-136.

Babin, B., Hair, J. F., Hair, J., Anderson, R., & Black, W. C. (2010). Multivariate data

analysis: A global perspective. London, UK: Pearson Education.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral

change. Psychological Review, 84(2), 191-215. doi.org/10.1016/0146-

6402(78)90002-4

Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive

Theory. Englewood Cliffs, New Jersey, Prentice-Hall.

Barber, J. G., & Crisp, B. R. (1995). Social support and prevention of relapse following

treatment for alcohol abuse. Research on Social Work Practice, 5(3), 283–296.

doi.org/10.1177/104973159500500302

133

Barkham, M., Hardy, G. E., & Startup, M. (1996). The IIP‐32: A short version of the

Inventory of Interpersonal Problems. British Journal of Clinical Psychology, 35(1),

21-35. doi.org/10.1111/j.2044-8260.1996.tb01159.x

Basker, V. G. (2013). A review on hazards of Khat chewing. International Journal of

Pharmacy and Pharmaceutical Sciences, 5(3), 74-77.

Baynesagne, M., Ayele, D., & Weldegerima, B. (2009). Prevalence, attitude and

associated problems of khat use among Bahir Dar University students, Northwestern

Ethiopia. Pharmacology Online, 1, 157-65.

Beattie, M. C., & Longabaugh, R. (1997). Interpersonal factors and post-treatment

drinking and subjective well-being. Addiction, 92(11), 1507–1521.

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring

clinical anxiety: Psychometric properties. Journal of Consulting and Clinical

Psychology, 56(6), 893-897. doi: 10.1037//0022-006x.56.6.893

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual forBeck Depression

Inventory-II. San Antonio, TX: Psychological Corporation.

Beck, A.T., Wright, F.D., Newman, C.F., Liese, B.S. (1993). Cognitive Therapy of

Substance Abuse. London, UK: Guilford Press.

Belew, M., Kebede, D., Kassaye, M., & Enquoselassie, F. (2000). The magnitude of khat

use and its association with health, nutrition and socio-economic status. Ethiopian

Medical Journal, 38(1), 11-26.

Benjamin, L. S. (2003). Interpersonal reconstructive therapy: Promoting change in

nonresponders. New York, USA: Guilford Press.

134

Benotsch, E. G., Jeffers, A. J., Snipes, D. J., Martin, A. M., & Koester, S. (2013). The

five factor model of personality and the non-medical use of prescription drugs:

Associations in a young adult sample. Personality and Individual Differences, 55(7),

852-855. doi.org/10.1016/j.paid.2013.06.004

Bentley, J., & Owens, C. (2008). Somali refugee mental health cultural profile.

Ethnomed. Retrieved from http://ethnomed.org/clinical/mental-health/somali-

refugee-mental-healthcultural-profile.

Bernhardt, N., Nebe, S., Pooseh, S., Sebold, M., Sommer, C., Birkenstock, J., ...&

Smolka, M. N. (2017). Impulsive Decision Making in Young Adult Social Drinkers

and Detoxified Alcohol‐Dependent Patients: A Cross‐Sectional and Longitudinal

Study. Alcoholism: Clinical and Experimental Research, 41(10), 1794-1807. doi:

10.1111/acer.13481.

Bimerew, M. S., Sonn, F. C. T., & Kortenbout, W. P. (2007). Substance abuse and the

risk of readmission of people with schizophrenia at Amanuel Psychiatric Hospital,

Ethiopia. Curationis, 30(2), 74-81. doi: 10.4102/curationis.v30i2.1078

Bjarnason T. (2003). Sampling issues in school surveys of adolescent substance use:

Conducting School Surveys on Drug Abuse. Vienna, Austria: United Nations Office

on Drugs and Crime.

Blaszczynski, A. P., Buhrich, N., &McConaghy, N. (1985). Pathological gamblers,

heroin addicts and controls compared on the EPQ ‘Addiction

Scale’. Addiction, 80(3), 315-319. doi: 10.1111/j.1360-0443.1985.tb02545.x

135

Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality

development, psychopathology, and the therapeutic process. Washington, DC:

American Psychological Association Press.

Bolger, N., DeLongis, A., Kessler, R. C., & Schilling, E. A. (1989). Effects of daily stress

on negative mood. Journal of Personality and Social Psychology, 57(5), 808-818.

doi: 10.1037//0022-3514.57.5.808

Bongard, S., al’Absi, M., Khalil, N. S., & Al Habori, M. (2011). Khat use and trait anger:

Effects on affect regulation during an acute stressful challenge. European Addiction

Research, 17(6), 285-291. doi: 10.1159/000330317

Brenneisen, R., Fisch, H. U., Koelbing, U., Geisshusler, S., & Kalix, P. (1990).

Amphetamine‐like effects in humans of the khat alkaloid cathinone. British Journal

of Clinical Pharmacology, 30(6), 825-828. doi: 10.1111/j.1365-2125.1990.tb05447.x

Brooke, C. (1960). Khat (Catha edulis): Its production and trade in the Middle East. The

Geographical Journal, 126(1), 52-59. doi: 10.2307/1790429

Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among

dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative

affect, positive affect, and autonomic arousal. Journal of Abnormal

Psychology, 107(2), 179-192. doi: 10.1037//0021-843x.107.2.179

Carmody, T. P., Delucchi, K., Simon, J. A., Duncan, C. L., Solkowitz, S. N., Huggins, J.,

... & Hall, S. M. (2012). Expectancies regarding the interaction between smoking and

substance use in alcohol-dependent smokers in early recovery. Psychology of

Addictive Behaviors, 26(2), 358-363. doi: 10.1037/a0024424.

136

Carroll, K. M. (1998). Therapy manuals for drug addiction, manual 1: A cognitive-

behavioral approach: Treating cocaine addiction. Rockville, Maryland: National

Institute on Drug Abuse.

Carroll, K. M., Rounsaville, B. J., Nich, C., Gordon, L. T., Wirtz, P. W., & Gawin, F.

(1994). One-year follow-up of psychotherapy and pharmacotherapy for cocaine

dependence: Delayed emergence of psychotherapy effects. Archives of General

Psychiatry, 51(12), 989-997. doi: 10.1001/archpsyc.1994.03950120061010

Caspi, A., Roberts, B. W., & Shiner, R. L. (2005). Personality development: Stability and

change. Annual Review of Psychology, 56, 453-484.

Cattell, R. B. (1966). The Scree test for the number of factors. Multivariate Behavioral

Research, 1(2), 245-276.

Clark, L. A., Watson, D., &Mineka, S. (1994). Temperament, personality, and the mood

and anxiety disorders. Journal of Abnormal Psychology,103(1), 103–116.

Cloninger, C. R. (1987a). Neurogenetic adaptive mechanisms in alcoholism.

Science, 236(4800), 410-416. doi: 10.1126/science.2882604

Cloninger, C. R. (1987b). A systematic method for clinical description and classification

of personality variants: A proposal. Archives of General Psychiatry, 44(6), 573-588.

doi: 10.1001/archpsyc.1987.01800180093014

Colizzi, M., & Murray, R. (2018). Cannabis and psychosis: what do we know and what

should we do?. The British Journal of Psychiatry, 212(4), 195-196. DOI:

10.1192/bjp.2018.1

137

Colzato, L. S., Ruiz, M. J., van den Wildenberg, W. P., & Hommel, B. (2011). Khat use

is associated with impaired working memory and cognitive flexibility. Plos

One, 6(6), 1-6. doi.org/10.1371/journal.pone.0020602

Conrod, P. J., Pihl, R. O., Stewart, S. H., & Dongier, M. (2000). Validation of a system of

classifying female substance abusers on the basis of personality and motivational risk

factors for substance abuse. Psychology of Addictive Behaviors, 14(3), 243–256.

DOI: 10.1037//0893-164x.14.3.243

Conway, K. P., Green, V. R., Kasza, K. A., Silveira, M. L., Borek, N., Kimmel, H. L., ...

& Reissig, C. J. (2018). Co-occurrence of tobacco product use, substance use, and

mental health problems among youth: Findings from wave 1 (2013–2014) of the

population assessment of tobacco and health (PATH) study. Addictive Behaviors, 76,

208-217. doi: 10.1016/j.addbeh.2017.08.009.

Conway, K. P., Swendsen, J. D., Rounsaville, B. J., & Merikangas, K. R. (2002).

Personality, drug of choice, and comorbid psychopathology among substance

abusers. Drug and Alcohol Dependence, 65(3), 225-234. DOI: 10.1016/s0376-

8716(01)00168-5

Costa, P. T., & McCrae, R. R. (1992). Four ways five factors are basic. Personality and

Individual Differences, 13(6), 653-665. doi.org/10.1016/0191-8869(92)90236-I

Costa, P. T., & McCrae, R. R. (1992). NEO PI-R: Professional manual. Odessa, Florida:

Psychological Assessment Resources.

Cox, G., & Rampes, H. (2003). Adverse effects of khat: A review. Advances in

Psychiatric Treatment, 9(6), 456-463. https://doi.org/10.1192/apt.9.6.456

138

Craske, M. G. (2010). Theories of psychotherapy: Cognitive–behavioral

therapy. Washington, DC, US: American Psychological Association.

Daley, S. E., Rizzo, C. J., & Gunderson, B. H. (2006). The longitudinal relation between

personality disorder symptoms and depression in adolescence: The mediating role of

interpersonal stress. Journal of Personality Disorders, 20(4), 352-368. doi:

10.1521/pedi.2006.20.4.352

Daniel, W.W. (1999). Biostatistics: A foundation for analysis in the health sciences

(7thed.). New York, USA: John Wiley & Sons.

Darharaj, M., Habibi, M., Kelly, A. B., Edalatmehr, Z., & Kazemitabar, M. (2017).

Predisposing personality traits and socio-familial factors of tendency toward

substance use among soldiers. Journal of Substance Use, 22(3), 310-316.

doi.org/10.1080/14659891.2016.1195896

Davis, C., & Loxton, N. J. (2013). Addictive behaviors and addiction-prone personality

traits: Associations with a dopamine multilocus genetic profile. Addictive

Behaviors, 38(7), 2306-2312. doi: 10.1016/j.addbeh.2013.02.012.

De La Haye, K., Green, H. D., Pollard, M. S., Kennedy, D. P., & Tucker, J. S. (2015).

Befriending risky peers: factors driving adolescents’ selection of friends with similar

marijuana use. Journal of Youth and Adolescence, 44(10), 1914-1928. doi:

10.1007/s10964-014-0210-z.

De Silva, P., &Eysenck, S. (1987). Personality and addictiveness in anorexic and bulimic

patients. Personality and Individual Differences, 8(5), 749-751.

doi.org/10.1016/0191-8869(87)90077-8

139

Dean, A. C., Hellemann, G., Sugar, C. A., & London, E. D. (2012). Educational

attainment is not a good proxy for cognitive function in methamphetamine

dependence. Drug and Alcohol Dependence, 123(1-3), 249-254. doi:

10.1016/j.drugalcdep.2011.11.019.

Dean, A. G., Sullivan, K. M., & Soe, M. M. (2014). Open Epi: Open source

epidemiologic statistics for public health, version 2.3. Available

from: http://www.OpenEpi.com

Del Pino-Gutiérrez, A., Jiménez-Murcia, S., Fernández-Aranda, F., Agüera, Z., Granero,

R., Hakansson, A., ...& Steward, T. (2017). The relevance of personality traits in

impulsivity-related disorders: From substance use disorders and gambling disorder to

bulimia nervosa. Journal of Behavioral Addictions, 6(3), 396-405. doi:

10.1556/2006.6.2017.051.

Deressa, W., & Azazh, A. (2011). Substance use and its predictors among undergraduate

medical students of Addis Ababa University in Ethiopia. BMC Public Health, 11(1),

1-11.

DeVellis, R. F. (2003). Scale development: Theory and applications (2nd ed.). Newbury

Park, CA, USA: Sage Publications.

Dhaifalah, I., & Santavy, J. (2004). Khat habit and its health effect: A natural

amphetamine. Biomedical Papers of the Medical Faculty of the University Palacky,

Olomouc, Czechoslovakia, 148(1), 11-15.

Dida, N., Kassa, Y., Sirak, T., Zerga, E., & Dessalegn, T. (2014). Substance use and

associated factors among preparatory school students in Bale Zone, Oromia Regional

140

State, Southeast Ethiopia. Harm Reduction Journal, 11(1), 1-7. doi: 10.1186/1477-

7517-11-21

Dimitrov, D. M., & Rumrill Jr, P. D. (2003). Pretest-posttest designs and measurement of

change. Work, 20(2), 159-165.

Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W.

(2008). A meta-analytic review of psychosocial interventions for substance use

disorders. American Journal of Psychiatry, 165(2) 179–187. doi:

10.1176/appi.ajp.2007.06111851.

Eberhart, N. K., &Hammen, C. L. (2006). Interpersonal predictors of onset of depression

during the transition to adulthood. Personal Relationships,13(2), 195-206.

doi.org/10.1111/j.1475-6811.2006.00113.x

Ehleringer, J. R., Casale, J. F., Lott, M. J., & Ford, V. L. (2000). Tracing the geographical

origin of cocaine. Nature, 408(6810), 311-312. doi: 10.1038/35042680

El-Menyar, A., Mekkodathil, A., Al-Thani, H., & Al-Motarreb, A. (2015). Khat use:

History and heart failure. Oman Medical Journal, 30(2), 77-82. doi:

10.5001/omj.2015.18

Elmi, A. S. (1983). The chewing of Khat in Somalia. Journal of

Ethnopharmacology, 8(2), 163-176. doi: 10.1016/0378-8741(83)90052-1

Elsohly, M. A. (2007). Marijuana and the Cannabinoids. New Jersey, USA: Springer

Science & Business Media.

Eshetu, E., & Gedif, T. (2006). Prevalence of khat, cigarette and alcohol use among

students of technology and pharmacy, Addis Ababa University. Ethiopian

Pharmaceutical Journal, 24(2), 116-124. doi.org/10.4314/epj.v24i2.35106

141

Eticha, T., Kahsay, G., Ali, D., Janapati, Y. K. (2016). Socio-economic and health effects

of khat chewing in Mekelle, Tigray region, Ethiopia. International Journal of

Pharmacy and Pharmaceutical Sciences, 8(1), 11-22.

Eysenck, H. J (1980). The causes and effects of smoking. London, UK: Temple Smith.

Eysenck, H. J. (1990). Genetic and environmental contributions to individual differences:

The three major dimensions of personality. Journal of Personality, 58(1), 245–261.

doi: 10.1111/j.1467-6494.1990.tb00915.x

Eysenck, S. B., Eysenck, H. J., & Barrett, P. (1985). A revised version of the

psychoticism scale. Personality and Individual Differences, 6(1), 21-29.

doi.org/10.1016/0191-8869(85)90026-1

Fairbairn, C. E., Sayette, M. A., Wright, A. G., Levine, J. M., Cohn, J. F., & Creswell, K.

G. (2015). Extraversion and the rewarding effects of alcohol in a social

context. Journal of Abnormal Psychology, 124(3), 660-673. doi:

10.1037/abn0000024

Farmer, A., Redman, K., Harris, T., Mahmood, A., Sadler, S., Pickering, A., &

McGUFFIN, P. (2002). Neuroticism, extraversion, life events and depression. The

British Journal of Psychiatry, 181(2), 118-122. doi: 10.1017/s0007125000161823

Ford, B. Q., & Mauss, I. B. (2015). Culture and emotion regulation. Current Opinion in

Psychology, 3, 1-5. doi: 10.1016/j.copsyc.2014.12.004

Foulds, J. A., Boden, J. M., Newton‐Howes, G. M., Mulder, R. T., &Horwood, L. J.

(2017). The role of novelty seeking as a predictor of substance use disorder

outcomes in early adulthood. Addiction, 112(9), 1629–1637. doi: 10.1111/add.13838.

142

Gashawa, A., & Getachew, T. (2015). The Chemistry of Khat and adverse effect of Khat

chewing. American Scientific Research Journal for Engineering, Technology, and

Sciences (ASRJETS), 9(1), 35-46.

Gebrehanna, E., Berhane, Y., & Worku, A. (2014). Khat chewing among Ethiopian

University Students-a growing concern. BMC Public Health, 14(1), 1-7. doi:

10.1186/1471-2458-14-1198.

Gebreslassie, M., Feleke, A., &Melese, T. (2013). Psychoactive substances use and

associated factors among Axum University students, Axum Town, North

Ethiopia. BMC Public Health, 13(1), 1-9.

Getahun, A., & Krikorian, A. D. (1973). Chat: coffee’s rival from Harar, Ethiopia. I.

Botany, cultivation and use. Economic Botany, 27(4), 353-377.

Getahun, W., Gedif, T., & Tesfaye, F. (2010). Regular Khat (Catha edulis) chewing is

associated with elevated diastolic blood pressure among adults in Butajira, Ethiopia:

A comparative study. BMC Public Health, 10(1), 1-8.

Gitonga, G. M., Ngeranwa, J., Machocho, A. K. O., Muthee, D. G., Kimutai, R., &

Gitonga, A. W. (2017). Nephrotoxicity effects of Khat (Catha edulis) on mice when

administered orally. The Journal of Phytopharmacology, 6(1), 27-33.

Goeders, N. E. (2004). Stress, motivation and drug addiction. Current Directions in

Psychological Science, 13, 33-35. doi.org/10.1111/j.0963-7214.2004.01301009.x

Golub, A., & Bennett, A. S. (2013). Introduction to the special issue: Drugs, wars,

military personnel, and veterans. Substance Use & Misuse, 48(10), 795-798. doi:

10.3109/10826084.2013.816859

143

Gorodnichenko Y., Roland G. (2012) Understanding the individualism-collectivism

cleavage and its effects: Lessons from cultural psychology. In M. Aoki, T. Kuran,

G. Roland (Eds.), Institutions and Comparative Economic Development (pp. 213-

236). London, UK: Palgrave Macmillan.

Gorski, T.T., & Miller, M. (1986). Staying sober: A guide for relapse prevention.

Missouri, US: Independence Press.

Gossop, M. and Eysenck, S. (1983). A comparison of the personality of drug addicts in

treatment with that of a prison population. Personality and Individual Differences,

4(2), 207-209.

Gossop, M. R. (1978). A comparative study of oral and intravenous drug-dependent

patients on three dimensions of personality. International Journal of the

Addictions, 13(1), 135-142. doi: 10.3109/10826087809039270

Gossop, M. R., & Eysenck, S. B. (1980). A further investigation into the personality of

drug addicts in treatment. Addiction, 75(3), 305-311. doi: 10.1111/j.1360-

0443.1980.tb01384.x

Gowing, L. R., Ali, R. L., Allsop, S., Marsden, J., Turf, E. E., West, R., & Witton, J.

(2015). Global statistics on addictive behaviours: 2014 status

report. Addiction, 110(6), 904-919. doi: 10.1111/add.12899.

Gowing, L. R., Ali, R. L., Allsop, S., Marsden, J., Turf, E. E., West, R., & Witton, J.

(2015). Global statistics on addictive behaviours: 2014 status

report. Addiction, 110(6), 904-919. doi: 10.1111/add.12899.

Gray, J. A. (1985). The neuropsychology of anxiety. Issues in Mental Health

Nursing, 7(14), 201-228.

144

Green, R. H. (1999). Khatt & the realities of Somalis: Historic, social, household,

political & economic. Review of African Political Economy, 26(79), 33-49.

Grekin, E. R., Sher, K. J., & Wood, P. K. (2006). Personality and substance dependence

symptoms: Modeling substance-specific traits. Psychology of Addictive

Behaviors, 20(4), 415-424. doi: 10.1037/0893-164X.20.4.415

Gurtman, M. B. (1995). Personality structure and interpersonal problems: A theoretically

guided item analysis of the Inventory of Interpersonal Problems. Assessment, 2(4),

343-361. doi.org/10.1177/1073191195002004005

Hailu, Y. M., Atlabachew, M., Chandravanshi, B. S., & Redi-Abshiro, M. (2017).

Composition of essential oil and antioxidant activity of Khat (Catha edulis Forsk),

Ethiopia. Chemistry International, 3(1), 25-31.

Hall, D., & Queener, J. (2007). Self-medication hypothesis of substance use: Testing

Khantzian's updated theory. Journal of Psychoactive Drugs, 39(2), 151- 158. doi:

10.1080/02791072.2007.10399873

Hall, W., & Weier, M. (2017). Lee Robins' studies of heroin use among US Vietnam

veterans. Addiction, 112(1), 176-180. doi: 10.1111/add.13584.

Hansen, P. (2010). The ambiguity of Khat in Somaliland. Journal of

Ethnopharmacology, 132(3), 590-599. doi.org/10.1016/j.jep.2010.02.028

Hanson, B. S. (1994). Social network, social support and heavy drinking in elderly men:

A population study of men born in 1914, Malmoe, Sweden. Addiction, 89(6), 725–

732. DOI: 10.1111/j.1360-0443.1994.tb00958.x

Hassan, N. A., Gunaid, A. A., El-Khally, F. M., & Murray-Lyon, I. M. (2002). The effect

of chewing Khat leaves on human mood. Neurosciences, 7(3), 184-187.

145

Havassy, B. E., Hall, S. M., & Wasserman, D. A. (1991). Social support and relapse:

Commonalities among alcoholics, opiate users, and cigarette smokers. Addictive

Behaviors, 16(5), 235-246. DOI: 10.1016/0306-4603(91)90016-b

Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective factors for

alcohol and other drug problems in adolescence and early adulthood: Implications

for substance abuse prevention. Psychological Bullentine, 112(1), 64–105. doi:

10.1037/0033-2909.112.1.64

Heath, D. B. (2001). Culture and substance abuse. Psychiatric Clinics of North

America, 24(3), 479-496.

Hirschfeld, R. M., Klerman, G. L., Lavori, P., Keller, M. B., Griffith, P., & Coryell, W.

(1989). Premorbid personality assessments of first onset of major

depression. Archives of General Psychiatry, 46(4), 345-350. doi:

10.1001/archpsyc.1989.01810040051008

Hoffman, R., & al’Absi, M. (2013). Working memory and speed of information

processing in chronic khat users: Preliminary findings. European Addiction

Research, 19(1), 1-6. doi: 10.1159/000338285

Horowitz, L. M., Rosenberg, S. E., & Bartholomew, K. (1993). Interpersonal problems,

attachment styles, and outcome in brief dynamic psychotherapy. Journal of

Consulting and Clinical Psychology, 61(4), 549-560. doi: 10.1037//0022-

006x.61.4.549

Hunter, A., Baker, E., Gladbaum, H., Hirani, K., Mashari, R., & McLennan, M. (2012).

The health and social impacts of Khat use in Brent. Brent, UK: Brent Council.

146

Intagliata, J. C. (1978). Increasing the interpersonal problem-solving skills of an

alcoholic population. Journal of Consulting and Clinical Psychology, 46(3), 489-

498. doi: 10.1037//0022-006x.46.3.489

Jessor, R., & Jessor, S. (1977). Problem behavior and psychosocial development: a

longitudinal study of youth. New York, USA: Academic Press.

Jibril, M., & Yusuf, I. (2012). Diverse effects of Khat on Somali families. Primary

Research Study (Undergraduate study), University College of Gävle. Retrieved from

www.diva-portal.se/smash/get/diva2:528472/FULLTEXT01.pdf

Johnson, V., & Pandina, R. J. (1991). Effects of the family environment on adolescent

substance use, delinquency, and coping styles. The American Journal of Drug and

Alcohol Abuse, 17(1), 71-88. doi: 10.3109/00952999108992811

Kalix, P., & Khan, I. (1984). Khat: An amphetamine-like plant material. Bulletin of the

World Health Organization, 62(5), 681-686.

Kaminer, Y., Burleson, J. A., & Goldberger, R. (2002). Cognitive-behavioral coping

skills and psychoeducation therapies for adolescent substance abuse. The Journal of

Nervous and Mental Disease, 190(11), 737-745. doi: 10.1097/00005053-200211000-

00003

Kassim, S., Croucher, R., & al'Absi, M. (2013). Khat dependence syndrome: Across

sectional preliminary evaluation amongst UK-resident Yemeni khat

chewers. Journal of Ethnopharmacology, 146(3), 835-841. doi:

10.1016/j.jep.2013.02.011

147

Kassim, S., Dalsania, A., Nordgren, J., Klein, A., & Hulbert, J. (2015). Before the ban-an

exploratory study of a local khat market in East London, UK. Harm Reduction

Journal, 12(1), 1-9. doi: 10.1186/s12954-015-0048-z.

Kassim, S., Islam, S., & Croucher, R. (2010). Validity and reliability of a Severity of

Dependence Scale for khat (SDS-khat). Journal of Ethnopharmacology, 132(3), 570-

577. doi: 10.1016/j.jep.2010.09.009.

Kassim, S., Islam, S., & Croucher, R. E. (2011). Correlates of nicotine dependence in UK

resident Yemeni khat chewers: a cross-sectional study. Nicotine & Tobacco

Research, 13(12), 1240-1249. doi: 10.1093/ntr/ntr180.

Kassim, S., Rogers, N., & Leach, K. (2014). The likelihood of khat chewing serving as a

neglected and reverse ‘gateway’ to tobacco use among UK adult male khat chewers:

a cross sectional study. BMC Public Health, 14(1), 1-11. doi: 10.1186/1471-2458-

14-448.

Katz, S. J., Conway, C. C., Hammen, C. L., Brennan, P. A., & Najman, J. M. (2011).

Childhood social withdrawal, interpersonal impairment, and young adult depression:

A mediational model. Journal of Abnormal Child Psychology, 39(8), 1227-1238.

doi: 10.1007/s10802-011-9537-z

Kebede, Y. (2002). Cigarette smoking and Khat chewing among college students in

North West Ethiopia. Ethiopian Journal of Health Development, 16(1), 9-17. doi:

10.4314/ejhd.v16i1.9818

Kelsey, J. L., Whittermore, A. S., Evans, A. S., & Thompson, W. D. (1996). Methods in

observational epidemiology. New York, USA: Oxford University Press.

148

Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A

reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-

244. DOI: 10.3109/10673229709030550

Klein, A., Jelsma, M., & Metaal, P. (2012). Chewing over Khat prohibition: The

globalization of control and regulation of an ancient stimulant. Transnational

Institute Series on Legislative Reform of Drug Policies, 17, 1-12.

Kline, P. (2013). The handbook of psychological testing. London, UK: Routledge.

Kline, P. 2014. An easy guide to factor analysis. London, UK: Routledge.

Kouimtsidis, C., Davis, P., Reynolds, M., Drummond, C., & Tarrier, N.

(2007). Cognitive-behavioural therapy in the treatment of addiction: A treatment

planner for clinicians. New Jersey, USA: John Wiley & Sons.

Kroll, J., Yusuf, A. I., & Fujiwara, K. (2011). Psychoses, PTSD, and depression in

Somali refugees in Minnesota. Social Psychiatry and Psychiatric

Epidemiology, 46(6), 481-493. doi: 10.1007/s00127-010-0216-0.

Krueger, R. F., Caspi, A., Moffitt, T. E., Silva, P. A., & McGee, R. (1996). Personality

traits are differentially linked to mental disorders: A multitrait-multidiagnosis study

of an adolescent birth cohort. Journal of Abnormal Psychology, 105(3), 299-312.

doi: 10.1037//0021-843x.105.3.299

Lamina, S. (2010). Khat (Catha edulis): the herb with officio-legal, socio-cultural and

economic uncertainty. South African Journal of Science, 106(3-4), 1-4.

Leach, D., & Kranzler, H. R. (2013). An interpersonal model of addiction

relapse. Addictive Disorders & Their Treatment, 12(4), 183. doi:

10.1097/ADT.0b013e31826ac408

149

Leonard, K., & Blane, H. (1999). Psychological theories of drinking and alcoholism (2nd

ed). New York, USA: Guilford press.

Leung, L., & Lee, P.S.N. (2012). The influences of information literacy, internet

addiction and parenting styles on internet risks. New Media & Society, 14(1), 115-

134. doi.org/10.1177/1461444811410406

Lieb, R., Merikangas, K. R., Höfler, M., Pfister, H., Isensee, B., & Wittchen, H. U.

(2002). Parental alcohol use disorders and alcohol use and disorders in offspring: A

community study. Psychological Medicine, 32(1), 63-78. doi:

10.1017/s0033291701004883

Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress

Scales. (2nd. Ed). Sydney, Australia: Psychology Foundation.

Luoma, J. B., & Platt, M. G. (2015). Shame, self-criticism, self-stigma, and compassion

in Acceptance and Commitment Therapy. Current Opinion in Psychology, 2, 97-101.

doi.org/10.1016/j.copsyc.2014.12.016

Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., & Fletcher, L. (2012). Slow and steady

wins the race: A randomized clinical trial of acceptance and commitment therapy

targeting shame in substance use disorders. Journal of Consulting and Clinical

Psychology, 80(1), 43-53. doi: 10.1037/a0026070.

Magdum, S. S. (2011). An overview of Khat. Addictive Disorders & Their

Treatment, 10(2), 72-83. doi: 10.1097/ADT.0b013e3181f002db

Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and

illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies

on Alcohol and Drugs, 70(4), 516-527. doi: 10.15288/jsad.2009.70.516

150

Mahfouz, M. S., Alsanosy, R. M., & Gaffar, A. M. (2013). The role of family

background on adolescent khat chewing behavior in Jazan Region. Annals of

General Psychiatry, 12(1), 1-8. doi: 10.1186/1744-859X-12-16.

Malouff, J. M., Thorsteinsson, E. B., Rooke, S. E., &Schutte, N. S. (2007). Alcohol

involvement and the Five-Factor Model of personality: A meta-analysis. Journal of

Drug Education, 37(3), 277-294. doi: 10.2190/DE.37.3.d

Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: A self-control strategy for

the maintenance of behavior change. New York: Guilford Press, 85-101. doi:

10.1186/1747-597X-6-17

Marlatt, G. A., Baer, J. S., Donovan, D. M., &Kivlahan, D. R. (1988). Addictive

behaviors: Etiology and treatment. Annual Review of Psychology, 39(1), 223-252.

doi: 10.1146/annurev.ps.39.020188.001255

Marsch, L. A., & Dallery, J. (2012). Advances in the psychosocial treatment of addiction:

The role of technology in the delivery of evidence-based psychosocial treatment. The

Psychiatric Clinics of North America, 35(2), 481-495. doi:

10.1016/j.psc.2012.03.009.

May, P. A. (1982). Substance abuse and American Indians: Prevalence and

susceptibility. International Journal of the Addictions, 17(7), 1185-1209. doi:

10.3109/10826088209056349

McCrady, B. S. (2004). To have but one true friend: implications for practice of research

on alcohol use disorders and social network. Psychology of Addictive

Behaviors, 18(2), 113-121. doi: 10.1037/0893-164X.18.2.113

151

McDonald, M. J., & Linden, P. D. (2003). Interpersonal problems and personality: Using

three factor solutions. Psychological Reports, 93(2), 371-377. doi:

10.2466/pr0.2003.93.2.371

McGue, M., Slutske, W., & Iacono, W. G. (1999). Personality and substance use

disorders: II. Alcoholism versus drug use disorders. Journal of Consulting and

Clinical Psychology, 67(3), 394-404. doi: 10.1037//0022-006x.67.3.394

McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for

substance use disorders. Psychiatric Clinics of North America, 33(3), 511-525. doi:

10.1016/j.psc.2010.04.012

Mikulincer, M., & Shaver, P. (2007). Attachment in adulthood: Structure, dynamics, and

change. New York, USA: Guilford Press.

Milani, L., Osualdella, D., & Di Blasio, P. (2009). Quality of interpersonal relationships

and problematic Internet use in adolescence. Cyber Psychology & Behavior, 12(6),

681-684. doi: 10.1089/cpb.2009.0071

Milanovic, B. (2008). Qat expenditures in Yemen and Djibouti: An empirical

analysis. Journal of African Economies, 17(5), 661-687.

Mueller, S. E., Degen, B., Petitjean, S., Wiesbeck, G. A., & Walter, M. (2009). Gender

differences in interpersonal problems of alcohol-dependent patients and healthy

controls. International Journal of Environmental Research and Public Health, 6(12),

3010-3022. doi: 10.3390/ijerph6123010

Mwenda, J. M., Arimi, M. M., Kyama, M. C., & Langat, D. K. (2004). Effects of Khat

(Catha edulis) consumption on reproductive functions: A review. East African

Medical Journal, 80(6), 318-323. doi: 10.4314/eamj.v80i6.8709

152

Nabuzoka, D., & Badhadhe, F. A. (2000). Use and perceptions of khat among young

Somalis in a UK city. Addiction Research, 8(1), 5-26.

doi.org/10.3109/16066350009004407

Nakajima, M., Dokam, A., Kasim, A.N., Alsoofi, M., Khalil, N.S., al'Absi, M. (2014).

Habitual khat and concurrent khat and tobacco use are associated with subjective

sleep quality. Preventing Chronic Disease,11, 1-8. doi: 10.5888/pcd11.130234

Nakajima, M., Hoffman, R., & Al'Absi, M. (2017). Level of khat dependence, use

patterns, and psychosocial correlates in Yemen: A cross-sectional investigation.

Eastern Mediterranean Health Journal, 23(3), 161-167.

Nakajima, M., Jebena, M. G., Taha, M., Tesfaye, M., Gudina, E., Lemieux, A., ...&

al'Absi, M. (2017). Correlates of khat use during pregnancy: A cross-sectional

study. Addictive Behaviors, 73, 178-184. doi: 10.1016/j.addbeh.2017.05.008.

Numan, N. (2012). The green leaf: Khat. World Journal of Medical Sciences, 7(4), 210-

223.

Nysæter, T. E., Langvik, E., Berthelsen, M., & Nordvik, H. (2009). Interpersonal

problems and personality traits: The relation between IIP-64C and NEO-FFI. Nordic

Psychology, 61(3), 82-93.

Odenwald, M., &Al'Absi, M. (2017). Khat use and related addiction, mental health and

physical disorders: The need to address a growing risk. Eastern Mediterranean

Health Journal, 23(3), 236-244.

Odenwald, M., Hinkel, H., Schauer, E., Neuner, F., Schauer, M., Elbert, T. R., &

Rockstroh, B. (2007). The consumption of khat and other drugs in Somali

153

combatants: A cross-sectional study. Plos Medicine, 4(12), 1959-1972. doi:

10.1371/journal.pmed.0040341

Odenwald, M., Hinkel, H., Schauer, E., Schauer, M., Elbert, T., Neuner, F., & Rockstroh,

B. (2009). Use of khat and posttraumatic stress disorder as risk factors for psychotic

symptoms: a study of Somali combatants. Social Science & Medicine, 69(7), 1040-

1048. doi: 10.1016/j.socscimed.2009.07.020.

Odenwald, M., Klein, A., & Warfa, N. (2015). Khat addiction. In N. El-Guebaly,

G. Carrà, & M. Galanter (Eds.), Textbook of addiction treatment: International

perspectives (pp.455-466). Retrieved from

https://link.springer.com/referenceworkentry/10.1007/978-88-470-5322-9_19

Odenwald, M., Lingenfelder, B., Peschel, W., Haibe, F. A., Warsame, A. M., Omer, A.,

...& Elbert, T. (2012). A pilot study on community-based outpatient treatment for

patients with chronic psychotic disorders in Somalia: Change in symptoms,

functioning and co-morbid Khat use. International Journal of Mental Health

Systems, 6(1), 1-17. doi: 10.1186/1752-4458-6-8.

Odenwald, M., Neuner, F., Schauer, M., Elbert, T., Catani, C., Lingenfelder, B., ...&

Rockstroh, B. (2005). Khat use as risk factor for psychotic disorders: A cross-

sectional and case-control study in Somalia. BMC Medicine, 3(1), 1-10. DOI:

10.1186/1741-7015-3-5

Omar, Y. S., Jenkins, A., Altena, M. V. R., Tuck, H., Hynan, C., Tohow, A., ... & Castle,

D. (2015). Khat use: What is the problem and what can be done? BioMed Research

International, 2015, 1-7. doi.org/10.1155/2015/472302

154

Osgood, D. W., Ragan, D. T., Wallace, L., Gest, S. D., Feinberg, M. E., & Moody, J.

(2013). Peers and the emergence of alcohol use: Influence and selection processes in

adolescent friendship networks. Journal of Research on Adolescence, 23(3), 500-

512. doi: 10.1111/jora.12059.

Othieno, C. J., Kathuku, D. M., & Ndetei, D. M. (2000). Substance abuse in outpatients

attending rural and urban health centres in Kenya. East African Medical

Journal, 77(11), 592-595. doi: 10.4314/eamj.v77i11.46728

Patel, N. B. (2000). Mechanism of action of cathinone: The active ingredient of Khat

(Catha Edulis). East African Medical Journal, 77(6), 329-332. doi:

10.4314/eamj.v77i6.46651

Patel, S. L., Murray, R., & Britain, G. (2005). Khat use among Somalis in four English

cities. London, UK: Home office.

Peters, D. W. (1952). Khat: Its history, botany, chemistry and toxicology-Pt. 1. The

Pharmaceutical Journal, 169, 16-17.

Petraitis, J., Flay, B., & Miller, T. (1995). Reviewing theories of adolescent substance

use: organizing pieces in the puzzle. Psychological Bulletine, 117(1), 67-86. doi:

10.1037/0033-2909.117.1.67

Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use

disorder: a complex comorbidity. Science & Practice Perspectives, 3(1), 13-21. doi:

10.1151/spp053113

Rawson, R. A., McCann, M. J., Flammino, F., Shoptaw, S., Miotto, K., Reiber, C., &

Ling, W. (2006). A comparison of contingency management and

155

cognitive‐behavioral approaches for stimulant‐dependent individuals.

Addiction, 101(2), 267-274. doi: 10.1111/j.1360-0443.2006.01312.x

Reda, A. A., Moges, A., Biadgilign, S., & Wondmagegn, B. Y. (2012). Prevalence and

determinants of khat (Catha edulis) chewing among high school students in eastern

Ethiopia: A cross-sectional study. Plos One, 7(3), 1-5. doi:

10.1371/journal.pone.0033946

Roberts, A. (2000). Psychiatric co morbidity in white and African_ American illicit

substance abusers: Evidence for etiology. Clinical Psychology Review, 20(5), 667-

677. doi.org/10.1016/S0272-7358(99)00020-3

Roberts, B. W. (2009). Back to the future: Personality and assessment and personality

development. Journal of Research in Personality, 43(2), 137-145. doi:

10.1016/j.jrp.2008.12.015

Robertson, E. B., David, S. L., & Rao, S. A. (2003). Preventing drug use among children

and adolescents: A research-based guide for parents, educators, and community

leaders. Maryland, USA: Diane Publishing.

Rodgers, T.B. (1995). The psychological testing enterprise: An introduction. Los

Angeles, USA: Brookes/Cole Publishing Company.

Rodriguez-Monguio, R., Brand, E., & Volberg, R. (2018). The economic burden of

pathological gambling and co-occurring mental health and substance use

disorders. Journal of Addiction Medicine, 12(1), 53-60. doi:

10.1097/ADM.0000000000000363.

Rosner, B. (2010). Fundamentals of Biostatistics (7thed.). Boston, USA: Brooks/Cole,

Cengage Learning.

156

Safhi, M. M., Alam, M. F., Hussain, S., Siddiqui, M. A. H., Khuwaja, G., Khardali, I. A.

J., ...& Islam, F. (2014). Cathinone, an active principle of Catha edulis, accelerates

oxidative stress in the limbic area of Swiss albino mice. Journal of

Ethnopharmacology, 156, 102-106. doi: 10.1016/j.jep.2014.08.004

Sahasi, G., Chawla, H. M., Bhushan, B., & Kacker, C. (1990). Eysenck's personality

questionnaire scores of heroin addicts in India. Indian Journal of Psychiatry, 32(1),

25-29.

Saleem, S., Ihsan, Z., & Mahmood, Z. (2014). Development of Interpersonal Difficulties

Scale for University Students. Pakistan Journal of Psychological Research, 29(2),

277-297. doi: 10.1037/t54691-000

Sallam, M. A., Sheikh, K. A., Baxendale, R., Azam, M. N., Hossain, A. M., & El-

Setouhy, M. (2018). The physiological and ergogenic effects of Khat (Catha

edulisForsk) extract. Substance Use & Misuse, 53(1), 94-100. doi:

10.1080/10826084.2017.1325375.

Sarvet, A. L., Wall, M. M., Keyes, K. M., Olfson, M., Cerdá, M., & Hasin, D. S. (2018).

Self-medication of mood and anxiety disorders with marijuana: Higher in states with

medical marijuana laws. Drug and Alcohol Dependence, 186, 10-15. doi:

10.1016/j.drugalcdep.2018.01.009

Scherer, K. (1997). College life on-line: Healthy and unhealthy Internet use. Journal of

College Student Development, 38(6),655-665.

Seo, M., Kang, H. S., & Yom, Y. H. (2009). Internet addiction and interpersonal

problems in Korean adolescents. CIN: Computers, Informatics, Nursing, 27(4), 226-

233. doi: 10.1097/NCN.0b013e3181a91b3f.

157

Sher, K. J., Bartholow, B. D., & Wood, M. D. (2000). Personality and substance use

disorders: A prospective study. Journal of Consulting and Clinical Psychology,

68(5), 818–829.

Sher, K.J., & Wood, M.D. (2005). Subjective effects of alcohol II: Individual differences.

In: M Earleywine (Ed.), Mind Altering Drugs: Scientific Evidence for Subjective

Experience (pp. 86–134). New York, USA: Oxford University Press.

Sigurdsson, J. F., & Gudjonsson, G. H. (1996). Psychological characteristics of juvenile

alcohol and drug users. Journal of Adolescence, 19(1), 41-46.

doi.org/10.1006/jado.1996.0004

Singh, M. (2012). Comparison of personality of alcoholics & drug addicts versus non-

alcoholics & non-drug addicts. International Journal of Science and Research, 1(3),

27-35.

Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7(4), 363-371.

Smith, G. M. (1970). Personality and smoking: Pi review of the empirical literature. In

W. A. Huint (Ed.), Learning mechanisms and smoking (pp. 42-71). Chicago, USA:

Aldine Transaction.

Soldz, S., Budman, S., Demby, A., &Merry, J. (1995). A short form of the Inventory of

Interpersonal Problems Circumplex Scale. Assessment, 2(1), 53–63.

doi.org/10.1177/1073191195002001006

Spielberger, C. D., & Jacobs, G. A. (1982). Personality and smoking behavior. Journal of

Personality Assessment, 46(4), 396-403. doi: 10.1207/s15327752jpa4604_11

158

Spotts, J. V., & Shontz, F. C. (1984). Drugs and personality:

Extraversion‐introversion. Journal of Clinical Psychology, 40(2), 624-628. doi:

10.1002/1097-4679(198403)40:2<624::aid-jclp2270400243>3.0.co;2-s

Stevenson, M., Fitzgerald, J., & Banwell, C. (1996). Chewing as a social act: Cultural

displacement and khat consumption in the East African communities of

Melbourne. Drug and Alcohol Review, 15(1), 73-82. doi:

10.1080/09595239600185691

Strug, D., & Hyman, M. (1981). Social networks of alcoholics. Journal of Studies on

Alcohol, 42(9), 855–884.

Szendrei, K. (1980). The chemistry of khat. Bulletin on Narcotics, 32(3), 5-35.

Teferra, S., Hanlon, C., Alem, A., Jacobsson, L., & Shibre, T. (2011). Khat chewing in

persons with severe mental illness in Ethiopia: A qualitative study exploring

perspectives of patients and caregivers. Transcultural Psychiatry, 48(4), 455-472.

doi: 10.1177/1363461511408494.

Teni, F. S., Surur, A. S., Hailemariam, A., Aye, A., Mitiku, G., Gurmu, A. E., &

Tessema, B. (2015). Prevalence, Reasons, and Perceived Effects of Khat Chewing

Among Students of a College in Gondar Town, Northwestern Ethiopia: A

Cross-sectional Study. Annals of Medical and Health Sciences Research, 5(6), 454-

460. doi: 10.4103/2141-9248.177992.

Tulloch, A. D., Frayn, E., Craig, T. K., & Nicholson, T. R. (2012). Khat use among

Somali mental health service users in South London. Social Psychiatry and

Psychiatric Epidemiology, 47(10), 1649-1656. doi: 10.1007/s00127-011-0471-8.

159

United Nations Office on Drugs and Crime. (2003). Conducting school survey on drug

abuse. Retrieved from:

https://www.unodc.org/.../GAP/GAP%20Toolkit%20Module%203%20ENGLISH.p

df

Van Der Vorst, H., Vermulst, A. A., Meeus, W. H., Deković, M., & Engels, R. C. (2009).

Identification and prediction of drinking trajectories in early and mid-

adolescence. Journal of Clinical Child & Adolescent Psychology, 38(3), 329-341.

doi: 10.1080/15374410902851648.

Vidrine, J. I., Cofta-Woerpel, L., Daza, P., Wright, K. L., & Wetter, D. W. (2006).

Smoking cessation 2: Behavioral treatments. Behavioral Medicine, 32(3), 99-109.

doi: 10.3200/BMED.32.3.99-109

Wabe, N. T. (2011). Chemistry, pharmacology, and toxicology of Khat

(cathaeduli`sforsk): A review. Addiction & Health, 3(3-4), 137-149.

Wackerly, D., Mendenhall, W., & Scheaffer, R. L. (2014). Mathematical statistics with

applications. Belmont, CA, USA: Cengage Learning.

Wanigaratne, S., Davis, P., Pryce, K., & Brotchie, J. (2005). The effectiveness of

psychological therapies on drug misusing clients. London, UK: National Treatment

Agency for Substance Misuse. Retrieved from:

file:///C:/Users/hp/Downloads/The_effectiveness_of_psychological_therapies_on_dr.

pdf

Warfa, N., Klein, A., Bhui, K., Leavey, G., Craig, T., & Stansfeld, S. A. (2007). Khat use

and mental illness: A critical review. Social Science & Medicine, 65(2), 309-318.

doi: 10.1016/j.socscimed.2007.04.038

160

Watson, D., Clark, L. A., & Carey, G. (1988). Positive and negative affectivity and their

relation to anxiety and depressive disorders. Journal of Abnormal Psychology, 97(3),

346-353. doi: 10.1037//0021-843x.97.3.346

Weir, S. (1985). Qat in Yemen: Consumption and social change. London, UK: British

Museum.

West, R. (2006). Theory of Addiction. Oxford, UK: Blackwell Publishing.

West, R., & Brown, J. (2013). Theory of addiction.West Sussex, UK: John Wiley &

Sons.

Westermeyer, J. (2004). Cross-cultural aspects of substance abuse. In M. Galanter, H.D.

Kleber, (Eds.), Textbook of substance abuse treatment (pp. 89-98). Arlington, VA:

American Psychiatric Publishing.

Widmann, M., Warsame, A. H., Mikulica, J., von Beust, J., Isse, M. M., Ndetei, D., ...&

Odenwald, M. G. (2014). Khat use, PTSD and psychotic symptoms among Somali

refugees in Nairobi–a pilot study. Frontiers in Public Health, 2(71), 1-10. doi:

10.3389/fpubh.2014.00071

Witkiewitz, K., &Marlatt, G. A. (2005). Emphasis on Interpersonal Factors in a Dynamic

Model of Relapse. American Psychologist, 60(4), 341-342. doi: 10.1037/0003-

066X.60.4.341

Wondemagegn, A. T., Cheme, M. C., &Kibret, K. T. (2017). Perceived psychological,

economic, and social impact of khat chewing among adolescents and adults in

Nekemte Town, East Welega Zone, West Ethiopia. Biomed Research

International, 2017, 1-9. doi.org/10.1155/2017/7427892

161

World Bank. (2001). Yemen: Country assistance evaluation. Washington, DC, USA:

World Bank.

World Health Organization. (2006). WHO Expert Committee on Drug Dependence:

Thirty-fourth report. Geneva, Switzerland: World Health Organization.

World Health Organization. (2010). A situation analysis of mental health in Somalia.

Retrieved from:

http://www.mhinnovation.net/sites/default/files/downloads/innovation/reports/A-SA-

of-MH-in-Somalia.pdf

World Health Organization. (2014). Definition of mental health. Retrieved from:

https://www.who.int/features/factfiles/mental_health/en/

Ying Ge, J. S., & Zhang, J. (2015). Research on relationship among internet-addiction,

personality traits and mental health of urban left-behind children. Global Journal of

Health Science, 7(4), 60-69. doi: 10.5539/gjhs.v7n4p60.

Young, K. (1998). Caught in the net: How to recognize the signs of internet addiction

and a winning strategy for recovery. New York, USA: John Wiley & Sons.

Zein, Z. A. (1988). Polydrug abuse among Ethiopian university students with particular

reference to khat (Catha edulis). The Journal of Tropical Medicine and

Hygiene, 91(2), 71-75.

162

Appendix A

Demographic Characteristics

Form no.________

Age________

Year of university (choose one): 1 year 2 year 3 year 4 year

163

Appendix B

Prevalence Questionnaire

Age________

Field of Study_____________________

1. Which year of university you are studying?

(a) 1 year (b) 2 year (c) 3 year (d) 4 year

2. Which region in Somalia you belong?

(a) Somaliland (b) Puntland (c) South-central Somalia

3. Have you used khat any time in your life?

(a) Yes (b) NO

4. Have you smoked Cigarette any time in your life?

(a) Yes (b) NO

5. Which pattern you use Khat mostly?

(a) Not Using (b) Alone (c) In-Group

6. Where you get the income you use Khat most of the time?

(a) Not Using (b) Job holder (c) Family

(d) Relatives (d)Friends (e) Others

7. How long have you been using Khat?

(a) Not Using (b) Less than 30 days (c) Less than 1 year

(d) 1-3 Years (e) 4-6 Years (e) More than 6 years

8. How regular you use Khat?

(a) Not Using (b) Once a Week (c) 2-4 Times a Week

(d) Daily

164

9. What type of Khat you use mostly?

(a) Not Using (b) Daba Musbar (c) Jabis

(d) Dadar (e) Boondaro (f) Others

10. How much time you spent on Khat per-day?

(a) Not Using (b) 1-4 hours (c) 5-8 hours

(d) More than 8 hours

11. Does your father use Khat?

(a) Yes (b) NO

12. Do any of your siblings use Khat?

(a) Yes (b) NO

13. Do you have a friend/s who uses Khat?

(a) Yes (b) NO

165

Appendix C

Demographic Sheet for Main Study

Age ____________

Year of university (choose one): 1 year 2 year 3 year 4 year

How regular you use Khat?

Daily Four times a week Twice a week

Once a week

How long have you been using Khat?

Less than 1 year 1-3 years 4-6 years

More than 6 years

How much time you spent on Khat per-day?

1-4 hours 5-8 hours More than 8 hours

Type of Khat Used: Daba Musbar Jabis Dadar

Bondaro Others

Chewing Khat: Alone In Group

Does anyone in your family (parent or sibling) chew khat? Yes No

If Yes, how many____________

v

v

166

Appendix D

Demographic Sheet for Intervention Study

Age ____________

Year of university (choose one): 1 year 2 year 3 year 4 year

How regular you use Khat?

Daily Four times a week Twice a week

Once a week

How long have you been using Khat?

Less than 1 year 1-3 years 4-6 years

More than 6 years

How much time you spent on Khat per-day?

1-4 hours 5-8 hours More than 8 hours

Type of Khat Used: Daba Musbar Jabis Dadar

Bondaro Others

Chewing Khat: Alone In Group

v

v

167

Appendix E

Khat Interpersonal Difficulties Scale (KIDS)

Instructions:

Following are some characteristics of people who use Khat. Please read

each item carefully and tell the extent to which it applies to you. There are

four options to choose from, circle only one option on each statement that

is applies to you.

(0) Not at all (1) Sometime (2) Often (3)

Always

No. Items Responses

1 I make friend only with Khat users 0 1 2 3

2 I feel nervous 0 1 2 3

3 I take risks 0 1 2 3

4 I try to convince friends to use Khat 0 1 2 3

5 I think about Khat all the time 0 1 2 3

6 I feel difficult to understand others 0 1 2 3

7 I do not talk to others 0 1 2 3

8 I make mistakes at work 0 1 2 3

9 I do not perform the religious duties regularly 0 1 2 3

10 I feel tension 0 1 2 3

11 I cannot do anything without chewing khat 0 1 2 3

12 I become angry easily 0 1 2 3

13 People do not like to be with me 0 1 2 3

14 I spend little time with people other than Khat users 0 1 2 3

15 I avoid fulfilling responsibility 0 1 2 3

16 I feel suspicious of others 0 1 2 3

17 I tell lies 0 1 2 3

168

18 I complain more about life 0 1 2 3

19 I steal 0 1 2 3

20 I cannot be relied as a friend 0 1 2 3

21 I am irritable 0 1 2 3

22 I ask for money from others 0 1 2 3

23 I break promises 0 1 2 3

24 I have frequent mood changes 0 1 2 3

25 I have a poor hygiene 0 1 2 3

26 I feel isolate from others 0 1 2 3

27 I lack concentration 0 1 2 3

28 I come late for an appointment 0 1 2 3

29 I have no goals in life 0 1 2 3

30 I cannot be trusted with money 0 1 2 3

31 I fight easily 0 1 2 3

32 I fear others to notice my weaknesses 0 1 2 3

33 I do not take care of my friends 0 1 2 3

Please make sure that you have answered EVERY question. Thank

you for your cooperation.

169

Appendix F

Depression Anxiety Stress Scale (DASS)

Instruction

Please read each statement and circle a number 0, 1, 2 or 3 which indicates

how much the statement applied to you over the past week. There are no

right or wrong answers. Do not spend too much time on any statement.

(1) Not at all (1) Sometime (2) Often (3)

Always

No. Items Responses

1 I found it hard to wind down

0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn't seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (eg, excessively rapid

breathing,

breathlessness in the absence of physical exertion)

0 1 2 3

5 I found it difficult to work up the initiative to do things 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I experienced trembling (eg, in the hands) 0 1 2 3

8 I felt that I was using a lot of nervous energy 0 1 2 3

9 I was worried about situations in which I might panic and make

a fool of myself

0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting agitated 0 1 2 3

12 I found it difficult to relax 0 1 2 3

13 I felt down-hearted and blue 0 1 2 3

14 I was intolerant of anything that kept me from getting on with

what I was doing

0 1 2 3

170

15 I felt I was close to panic 0 1 2 3

16 I was unable to become enthusiastic about anything 0 1 2 3

17 I felt I wasn't worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I was aware of the action of my heart in the absence of physical

exertion (eg, sense of heart rate increase, heart missing a beat)

0 1 2 3

20 I felt scared without any good reason 0 1 2 3

21 I felt that life was meaningless 0 1 2 3

171

Appendix G

Eysenck Personality Questionnaire Revised Short Form (EPQ-RS)

Instructions:

Please answer each question by putting a circle around the ‘YES or the ‘NO’

following the question. There are no right or wrong answers, and no trick

questions. Work quickly and do not think too long about the exact meaning

of the questions.

PLEASE REMEMBER TO ANSWER EACH QUESTION

NO. QUESTIONS RESPONSES

1 Does your mood often go up and down? YES NO

2 Do you take much notice of what people think? YES NO

3 Are you a talkative person? YES NO

4 If you say you will do something, do you always keep your

promise no matter how inconvenient it might be?

YES NO

5 Do you ever feel ‘just miserable for no reason? YES NO

6 Would being in debt worry you? YES NO

7 Are you rather lively? YES NO

8 Were you ever greedy by helping yourself to more than your

share of anything?

YES NO

9 Are you an irritable person? YES NO

10 Would you take drugs which may have strange or dangerous

effects?

YES NO

11 Do you enjoy meeting new people? YES NO

12 Have you ever blamed someone for doing something you knew

was really your fault?

YES NO

13 Are your feelings easily hurt? YES NO

172

14 Do you prefer to go your own way rather than act by the rules? YES NO

15 Can you usually let yourself go and enjoy yourself at a lively

party?

YES NO

16 Are all your habits good and desirable ones? YES NO

17 Do you often feel ‘fed-up.? YES NO

18 Do good manners and cleanliness matter much to you? YES NO

19 Do you usually take the initiative in making new friends? YES NO

20 Have you ever taken anything (even a pin or button) that

belonged to someone else?

YES NO

21 Would you call yourself a nervous person? YES NO

22 Do you think marriage is old-fashioned and should be done

away with?

YES NO

23 Can you easily get some life into a rather dull party? YES NO

24 Have you ever broken or lost something belonging to someone

else?

YES NO

25 Are you a worrier? YES NO

26 Do you enjoy co-operating with others? YES NO

27 Do you tend to keep in the background on social occasions? YES NO

28 Does it worry you if you know there are mistakes in your

work?

YES NO

29 Have you ever said anything bad or nasty about anyone? YES NO

30 Would you call yourself tense or ‘highly-strung’? YES NO

31 Do you think people spend too much time safeguarding their

future with savings and insurances?

YES NO

32 Do you like mixing with people? YES NO

33 As a child were you ever cheeky to your parents? YES NO

34 Do you worry too long after an embarrassing experience? YES NO

35 Do you try not to be rude to people? YES NO

36 Do you like plenty of bustle and excitement around you? YES NO

173

37 Have you ever cheated at a game? YES NO

38 Do you suffer from ‘nerves’? YES NO

39 Would you like other people to be afraid of you? YES NO

40 Have you ever taken advantage of someone? YES NO

41 Are you mostly quiet when you are with other people? YES NO

42 Do you often feel lonely? YES NO

43 Is it better to follow society’s rules than go your own way? YES NO

44 Do other people think of you as being very lively? YES NO

45 Do you always practice what you preach? YES NO

46 Are you often troubled about feelings of guilt? YES NO

47 Do you sometimes put off until tomorrow what you ought to do

today?

YES NO

48 Can you get a party going? YES NO

PLEASE CHECK THAT YOU HAVE ANSWERED ALL THE

QUESTIONS

174

Appendix H

IIP-Short

Instructions:

This is a series of questions relating to different aspects of each of our lives.

Each question has four possible answers. Please mark the number which

expresses your answer, with the numbers 0 and 4 being extreme answers. If

the words under 0 are right for you, circle 0; if the words under 4 are right

for you, circle 4. If you feel differently, circle the number which best

expresses your feeling. Please give only one answer to each question.

(2) Not at all (1) A little bit (2) Moderately (3) Quite a bit (4)

Extremely

No. Questions Responses

1 It is hard for me to understand another person’s point of view. 0 1 2 3 4

2 I let other people take advantage of me too much. 0 1 2 3 4

3 I want to be noticed too much. 0 1 2 3 4

4 I keep other people at a distance too much. 0 1 2 3 4

5 It is hard for me to socialize with other people. 0 1 2 3 4

6 I open up to people too much. 0 1 2 3 4

7 I put other people’s needs before my own too much. 0 1 2 3 4

8 It is hard for me to join in groups. 0 1 2 3 4

9 It is hard for me to feel close to other people. 0 1 2 3 4

10 I argue with other people too much. 0 1 2 3 4

11 It is hard for me to be supportive of another person’s goals in

life.

0 1 2 3 4

12 It is hard for me to show affection to people. 0 1 2 3 4

13 It is hard for me to be assertive without worrying about hurting

the other person’s feelings.

0 1 2 3 4

175

Please make sure that you have answered EVERY question. Thank

you for your cooperation.

14 I am too suspicious of other people. 0 1 2 3 4

15 I try to please other people too much. 0 1 2 3 4

16 It is hard for me to tell a person to stop bothering me. 0 1 2 3 4

17 It is hard for me to experience a feeling of love for another

person.

0 1 2 3 4

18 I try to control other people too much. 0 1 2 3 4

19 I am easily persuaded by other people. 0 1 2 3 4

20 I tell personal things to other people too much. 0 1 2 3 4

21 It is hard for me to be firm when I need to be. 0 1 2 3 4

22 It is hard for me to feel good about another person’s happiness. 0 1 2 3 4

23 It is hard for me to be assertive with another person. 0 1 2 3 4

24 I am affected by another person’s misery too much. 0 1 2 3 4

25 It is hard for me to keep things private from other people. 0 1 2 3 4

26 It is hard for me to attend to my own welfare when somebody

else is needy.

0 1 2 3 4

27 It is hard for me to let other people know when I am angry. 0 1 2 3 4

28 It is hard for me to confront people with problems that come

up.

0 1 2 3 4

29 It is hard for me to introduce myself to new people. 0 1 2 3 4

30 I want to get revenge against people too much. 0 1 2 3 4

31 It is hard for me to ask other people to get together socially

with me.

0 1 2 3 4

32 I am too aggressive toward other people. 0 1 2 3 4

176

Appendix I

177

Appendix J

178

Appendix K

179

Appendix L

180

Appendix M