Comparative Analysis of Academic Performance According to Substance Use Status of Students of Ambo University, College of Medicine and Health Sciences, Ethiopia

Background. Studies have shown that students use substances for different reasons including: to enhance their academic performance, for stimulant effect, to overcome stress and to be integrated with substance using community (groups). The aim of this study was to test whether the academic performance of substance user is different from that of non-substance user students. Methods. Cross sectional study design was employed to analyze the academic performance of 133 (60 substance users and 73 non-users) undergraduate graduates of 2017 at Ambo University, College of medicine and health sciences. Independent t-test was performed to compare substance user students’ academic performance with that of non-substance user students. Results. Out of the study participants, 60(45.1%) have used at least one of the substances (alcohol, khat or cigarette). The most commonly used substance was alcohol. The average cumulative grade point (CGPA) of substance users was 3.20 (SD=0.42) while it was 3.16 (SD=0.45) for non-substance users. CGPA mean difference between substance user and non-substance students was not statistically significant (Mean difference=0.04; 95% CI: -0.11 to 0.19; t=0.549,df=131, p-value=0.584). Conclusion. The findings suggest that substance users and non-substance users students’ academic performance was similar. The hypothesis test result was against substance user students’ perception of substance use to enhance academic performance. Therefore, substance user students were compromised their health and social functioning for no more better educational attainment than non-substance user students. Keywords: Academic performance, comparative analysis, independent t-test, substance use. DOI : 10.7176/JHMN/67-01 Publication date :October 31 st 2019


Background
Substance use refers to the use of psychoactive substances, including alcohol and illicit drugs. According to Ethiopia Demographic and Health Survey,2016 report, 4% of men and < 1% of women smoke cigarettes, 35% of women and 46% of men reported drinking alcohol at some point in their lives and 12% of women and 27% of men reported having ever chewed khat [1].
The use of substances such as alcohol, khat(Catha edulis; a green leaf chewed for its stimulant effect), and tobacco is becoming common in the universities of Ethiopia. Universities are relatively the place where students easily practice their own choices compared to high schools. The involvement of parents in the academic activities of the students at university is less. Studies show that prevalence of substance use varies across different universities. According to the previous studies, alcohol use prevalence among university students ranges from 11.4% [2] to 68% [3]. Cigarette smoking prevalence ranges from 10% [4] to 73% [3] while khat chewing prevalence ranges from 6.9% [5] to 35% [6].

Pushing Factors of Substance Use among University Students
Several pushing factors of substance use among university students can be classified into external and internal factors. External factors include socio-cultural influences and peer pressure. Studies reveal that socio-culture has an impact on students' substance use status. For instance, a qualitative research done by Dázio [7] shows that male university students share the rules of their socio-cultural environment that values the use of alcohol and/or other drugs to cope with stress ensuing from the everyday university life, and to build identity and belong to this social context, reinforcing the influence of the culture. Similarly, a study done in Jimma university shows that social background (whether or not khat grows in the student's home region) has positive significant association with khat use at university [6]. Several studies done on substance use in the universities show that peer pressure is the most frequently reported factor by the students for the initiation of substance use [4,6,[8][9][10][11][12][13][14][15]. Study done by Dachew [16] shows that students who had friends who chewed khat were about four times more likely to use khat as compared to those who do not have khat chewer friends.

Impact of substance use
Use of substance for any reason has multiple consequences including health, social and academic problems. Regarding the health effects of substance use, many researchers find out several health outcomes including psychiatric morbidities [9,14,17,18,24], periodontitis [9,14,25,26], risk behavior for HIV/AIDS [26], problems of blood pressure [26,27], heart rate [27] and digestive system [18,24]. Since substance users exhibit deviant behavior, the society considers them as a threat to the other member of the society [28]. Therefore, substance use impairs occupational and social functioning of the user. Similarly, studies have shown that substance use affects academic performances of the students [8]. Unlike the expectation of substance users, some studies reveal that substance user students' academic performance is lower than that of non-users [6,28,29]. This might be because of the high absenteeism rate from class and exam among substance users [30].
Irrespective of all of these evidences against substance use, students in Ethiopia universities use substances especially khat to enhance their academic performance. Therefore, this study was aimed to compare the academic performance of substance user with that of non-substance user students. Independent t-test was performed to test whether substance users' academic performance is better than the non-substance users as they perceived. The finding of this study is useful in planning and developing different strategies to help students quit substance use.

Objective of the Study
The objective of this study was to test whether the academic performance of substance user undergraduate students is different from that of non-substance users.

Study Design
In this study, quantitative cross sectional study design was employed to compare academic performance of substance users with academic performance of non-substance users.

Study Population
The study population for this study was all regular undergraduates of health sciences who were graduated at Ambo University in 2017.

Sample size
The study comprises 170 undergraduate students who were recruited in Public health, Nursing, Pharmacy and Midwifery programs run under the college.

Data Collection Method
Since the population size was relatively small (N=170), census survey was conducted to get a full picture of the target population.

Data Collection Instrument
The data was collected using anonymous self administered questionnaire developed to collect data to achieve the study's objective. The content of the questionnaire includes the socio-demographic characteristics, substance use status and academic performance indicator variables.

Study variables 2.6.1. Dependent variables.
The dependent variable of this study was academic performance measured by:  UEES: Standardized university entrance examination score out of 700 points the students achieved at grade 12 which was administered by ministry of education and  CGPA: Cumulative grade point averages out of 4.00 points they achieved at university in the final year.

The independent variable
Independent variables of the study include sex, department, residence, religion and ethnic group and substance use status of the students. In this study, substance use status which refers to whether a student has been using at least one of the substances (alcohol, khat or cigarette) was used as a stratifying factor in comparing academic performance of the students.

Statistical Analysis 2.7.1. Hypothesis formulation
Two sided hypothesis was formulated to answer the research question: "is there a significant The significance level    of the hypothesis test was set to 0.05.

Test statistic
Under the null hypothesis   0 : Since the test is two sided, P-value is computed as: Then, P-value is compared with the significance level    to suggest the observed difference in mean CGPA between the two groups is significant or not.

Software Used
Statistical analysis was performed using SPSS version 21. Both descriptive and inferential statistical analyses were performed. Socio-demographic, substance use status and academic performance indicator variables of the study participants were summarized by descriptive statistics. Then, independent samples t-test was done to test the significance of mean difference in UEES and CGPA between substance user and non-substance user students. Pvalue < 0.05 was considered to be statistically significant.

Results
This part contains the result of the study and presented thoroughly. The questionnaires were distributed to all of the students consisting 170(125 males and 45 females) undergraduates from the four programs. However, only 133(92 male and 41 female) graduates successfully completed and returned the questionnaires, yielding a response rate of 78.2%. Therefore, data from 133 completed questionnaires were used for the analysis in this study.

Substance use status of the study participants
Out of the study participants 60(45.1%) have used at least one of the substances (alcohol, khat or cigarette). Regarding the prevalence of each substance use, 54(40.6%) have used alcohol, 20(15.0%) khat and 4(3.0%) cigarette (table 3.2).

Descriptive summary of the students' academic Performance
As can be seen from  .000 As can be seen from table 3.5, Levene's Test for Equality of Variances shows, variability of university entrance exam score among substance user students was similar with the variability of non-substance users (F=0.003,p-value= 0.96). Similarly, variability of average cumulative grade point (CGPA) among substance user students was similar with the variability of non-substance users (F=0.036,p-value= 0.850).
As revealed in table 3.5, independent samples t-test results show that there was no significant mean difference in UEES achievement between substance user and non-substance user students (Mean difference= 4.34; 95% CI= -4.8 to 13.5; t=0.939,df=131, p-value=0.349). The average cumulative grade point (CGPA) of substance user students was not also statistically significantly different from that of non-substance users (Mean difference= 0.04; 95% CI= -0.11 to 0.19; t=0.549,df=131, p-value=0.584).

Discussion
The purpose of this study was to compare academic performance of substance user and non-substance user undergraduate students. The attempt was also made to estimate the proportion of the graduates using alcohol, khat and cigarette. Even though this study addressed all of the 170 undergraduate graduates of 2017 from the four programs run under the college of Medicine and Health Sciences, only 133 of them successfully completed and returned the questionnaire yielding 78.2% response rate. Prevalence of at least use of one of the substances: alcohol, khat or cigarette among ambo University undergraduate students is 60(45.1%). According to the finding of the study, 40.6% of undergraduates have used alcohol, 15.0% khat and 3.0% cigarette. The most commonly used substance among Ambo University students is alcohol while cigarette was rarely used accounting only 3%.
Prevalence of alcohol use in among Ambo university students is higher than that of the other Ethiopia universities students [2,4,9,13]. However, there are also other universities whose students' alcohol use prevalence Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.67, 2019 6 is higher than Ambo university's students [15,19]. Regarding khat use, prevalence of khat chewing among students of majority of other universities in the country [4,6,13,14,15,18,19,23] is higher than the prevalence of khat chewing among Ambo university students. In contrary, in few universities [5,12,16] prevalence of their students' khat use is less than that of Ambo University students. When cigarette use concerned, Ambo University students rarely use it compared to the research result from the other Ethiopia University [4]. The discrepancies in prevalence of substances might be because of socio-cultural norm differences in the different areas towards substance use. For instance khat use proportion in Ambo University is lower than other universities because of the fact that Ambo University is not located in khat growing area.
Levene's Test of Equality of variances shows that equality of variances assumption was met in both university entrance examination score (F=0.003, P-value=0.96) and CGPA (F=0.036, P-value=0.850) distributions.
However, test of normality suggests that both academic performance indicators (university entrance examination score and CGPA) distributions violet normality assumption. Even though, the distributions of academic performance indicators in each group violet normality assumption, Central Limit Theorem was taken into consideration as the sample size in each group was large enough   30  n . Therefore, independent samples t-test produces valid statistical inferences in this case.
The average university entrance exam score of substance user was 440.7 (SD=26.2) compared to 436.3(SD=26.7) for non-substance user students. Independent t-test result shows that both substance user and nonsubstance user students joined the university with similar level of high school academic performance (Mean difference=4.34; 95%CI: -4.8 to 13.5; t=0.94,df=131, p-value=0.35). Average cumulative grade point average (CGPA) of substance user graduates was 3.20 (SD= 0.42) while it was 3.16 (SD=0.45) for non-substance users. Similarly, the average cumulative grade point (CGPA) of substance user undergraduates was not statistically significantly different from that of non-substance users (Mean difference=0.04; 95%CI: -0.11 to 0.19; t=0.549,df=131, p-value=0.584). In contrast, the previous studies have reported that substance user students' academic performance was lower than that of the non-substance users [6,28,29]. In this study, the hypothesis test result was against substance user students' perception of substance use to enhance academic performance.

Conclusion
Studies have shown that students use substances for different reasons including: to enhance their academic performance, for stimulant effect, to overcome stress and to be integrated with substance using community (groups). Prevalence of using at least one of the substances: alcohol, khat or cigarette among ambo University undergraduate students was 60(45.1%). The most commonly used substance was alcohol while cigarette was rarely used accounting only 3% of the study participants. There was inconsistence prevalence of substance uses among Ethiopia Universities' students. Since substance use is learned behavior, the discrepancies in prevalence of substance use among the students could be due to socio-cultural norm difference towards substance use.
The hypothesis test results show that the substance user and non-user students' academic performance was similar both in university entrance exam score and CGPA. Therefore, substance user students were compromised their health and social functioning for no more better educational attainment than non-substance user students. Thus, this study finding implies that the use of substances to enhance academic performance is wrong perception and harmful practice.

Declarations
 Ethics approval and consent to participate The study was approved by Research and Ethical Review Committee of College of Medicine and Health Sciences, Ambo University. Since the study does not involve activities that affect the participants in any ways, the committee approved verbal informed consent. Accordingly, verbal informed consent was obtained from the study participants.  Consent to publish Not applicable  Availability of data and materials Data used for this study is available from the author on reasonable request  Competing interests There is no potential conflict of interest to disclose in this study

 Funding
There was no financial support received from any institution for this study.

 Authors' Contributions
Not applicable