Research Thesis Personality Traits, Interpersonal ...
Transcript of 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
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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.
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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.
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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).
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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
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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
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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
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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
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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
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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
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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
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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…
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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
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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.
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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).
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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)
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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.
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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.
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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%
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(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.
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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.
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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.
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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
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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.
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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
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that they experience more depression and show more positive impression then those chew
khat in-group.
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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.
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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)
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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.
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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)
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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.
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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.
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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
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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.
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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
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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
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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
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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