1

ACADEMIC PERFORMANCE OF SUBSTANCE

ABUSING SECONDARY SCHOOL STUDENTS IN

ABAKALIKI.

A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE

MEDICAL COLLEGE IN PART FULFILMENT OF THE

REQUIREMENTS FOR THE AWARD OF FELLOWSHIP OF THE

COLLEGE IN THE FACULTY OF PEDIATRICS.

BY DR ANYANWU, ONYINYE UCHENNA

MBBS (SEPTEMBER 2001)

EXAMINATION DATE: MAY 2015

2

DECLARATION

I hereby declare that this work, titled “ACADEMIC PERFORMANCE OF

SUBSTANCE ABUSING SECONDARY SCHOOL STUDENTS IN ABAKALIKI.”,

is original unless otherwise acknowledged. This work has neither been presented to

any College for the award of Fellowship, nor submitted elsewhere for publication.

..............................................................................

ANYANWU, ONYINYE UCHENNA

DATE ………………………………………….

3

ATTESTATION

The study reported in this dissertation was carried out by the candidate Anyanwu

Onyinye Uchenna under our supervision. We also supervised the writing of the

dissertation.

PROF. N.C OJINNAKA.

CONSULTANT PAEDIATRICIAN

UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU

SIGNATURE___________________________________

DATE ________________________________________

DR R.C. IBEKWE

CONSULTANT PAEDIATRICIAN

UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU

SIGNATURE___________________________________

DATE ________________________________________

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TABLE OF CONTENTS

PAGE

Title i

Declaration ii

Attestation iii

Table of contents iv

List of abbreviations vi

Definitions viii

List of Tables x

List of appendices xii

Dedication xiii

Acknowledgement xiv

Summary xv

Introduction and Justification 1

Literature review 5

Aims and objectives 28

Participants and methods 29

Results 40

Discussion 57

5

Conclusion 64

Recommendation 65

Limitations 66

Lines of future study 67

References 68

Appendices 81

6

LIST OF ABBREVIATIONS

ADI-Adolescent Drinking Index

ASADA-Assessing the Seriousness of Adolescent Drug Abuse.

ASI-Addiction Severity Index

AUDADIS-Alcohol Use Disorders and Associated Disabilities Interview Schedule

CAGE- Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers.

CBCL-Child Behavior Checklist.

CIDI-Composite International Diagnostic Interview

Conner's CBRS-Conner's Comprehensive Behaviour Rating Scales.

CRAFFT- Car (have you ever been driven in the car of someone high on drugs?) Relax (do

you use drugs to relax?) Alone (do you use drugs while alone?) Friends/family (has your

friends or family members felt you had a drug problem?) Forget (do you forget/regret the

things you did while using drugs? ) Trouble (have you ever gotten into trouble for using

drugs?)

IQ-Intelligence Quotient.

LGA-Local Government Area.

NECO-National Examinations Council.

PESQ-Personal Experience Screening Questionnaire

PIAT-Peabody Individual Achievement Test.

PRISM-Psychiatric Research Interview for Substance and Mental Disorders

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PSC-Pediatrics Symptom Checklist.

SAT-M Score-Scholastic Aptitude Test Mathematics score.

SCID-Structured Clinical Interview for DSM-IV

SCPS-School Children Problem Scale.

SDQ-Strength and Difficulty Questionnaire.

SPSS-Statistical Package for Social Sciences.

SSADDA-Semi-Structured Assessment for Drug Dependence and Alcoholism.

SSCE-Senior Secondary Certificate Examination.

TRF-Teacher Report Form.

UBE-Universal Basic Education.

WAEC-West African Examinations Council

WASC-West African School Certificate.

WHO-World Health Organization..

WRAT-Wide Range Achievement Test.

YSR-Youth Self Report.

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DEFINITIONS

SUBSTANCE: A substance is any psychoactive or mood altering agent that is consumed for

pleasurable or other reasons rather than therapeutic purposes and also possesses habit forming

potential.

LICIT AND ILLICIT SUBSTANCES: Licit substances are substances which are not

prohibited by law example alcohol, coffee, kola nut and cigarette. While illicit substances are

substances whose use and possession are prohibited by law such substances are cannabis,

cocaine, and heroine.

SUBSTANCE USE: This implies that a person is in control of his/her use of a substance, or

is using it in a manner that is not harmful to health and is experiencing no social or

occupational impairment from its use. However for illicit substances they are liable for

possession and use of the substance prohibited by law.

SUBSTANCE ABUSE: The use of substances when they are not physiologically or

pharmacologically necessary; when they are used against legal prohibition like any use of

illicit drugs, or when there is a culturally inappropriate as well as excessive use of socially

acceptable substances like alcohol and tobacco especially if the abuser is unable to stop the

use of the substance. There is continuous abuse within 30days before the survey.

CURRENT SUBSTANCE USE: Substance abuse in the past 12months with continuous use

within 30days before the survey.

LIFETIME SUBSTANCE USE: Use of substance at least once in life.

PAST USE OF SUBSTANCE: Substance use but not within the last 12 months before the

survey.

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DEPENDENCE: This occurs when a person is unable to lead a normal life without ingesting

the substance he is depended on. Psychological dependence implies that there is craving or an

overpowering drive or desire for the use of the substance to avoid discomfort that may arise

from not using the substance.

ADDICTION: It is a specific cluster of symptoms experienced by the addict when the

substance is abruptly or completely withdrawn, e.g. delirium tremens occurring in alcoholics

who suddenly withdraws from taking alcohol.

ACADEMIC PERFORMANCE: It is the extent to which a student has achieved his or her

educational goal. It is usually measured by performances in school examinations and

continuous assessment.

ADOLESCENT: Adolescence is defined by World Health Organisation (WHO) as the age

between 10-19 years, and is characterized by increased adventurous tendencies and peer

influences. Hence an adolescent is one aged 10 to 19 years.

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LIST OF TABLES

Page

Table I: Number of Respondents and Number of Substances Abused 40

Table II: Socio-demographic characteristics of subjects and controls 41

Table III: Prevalence of Substance Abuse 42

Table IV: Prevalence of individual and combination substances of abuse. 43

Table V: Prevalence of Substance abuse within Age groups 44

Table VI: Prevalence of Substance abuse according to Gender 45

Table VII: Association between substance abuse and age at first use 46

Table VIII: Family structure of total respondents and its association with abuse of various

substances 48

Table IX: Overall academic score of subjects and control 49

Table X: Mean scores of subjects and controls in selected key class subjects and their overall

score 50

Table XI: Association between school absence and overall academic score of subjects and

controls 51

Table XII: Association between psychosocial dysfunction and overall academic score of

substance abusers and controls 52

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Table XIII: Academic performance of subjects using different substances of abuse. 53

Table XIV: Association between the number of substances abused and overall academic score

of subjects 55

Table XV: Multiple regression analysis of factors associated with academic performance of

substance abusers and controls 56

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LIST OF APPENDICES

Page

APPENDIX I: Letter of ethical approval from research and ethics committee Federal

Teaching Hospital Abakaliki (FETHA). 81

APPENDIX II: Letter of introduction from Ministry of Education Ebonyi. 83

APPENDIX III: Consent letter (students). 84

APPENDIX IV: Consent letter (parents/guardian). 86

APPENDIX V: Consent letter (principal) 88

APPENDIX VI: WHO student’s drug use questionnaire. 89

APPENDIX VII: Social classification by OLUSANYA et al 108 99

APPENDIX VIII: Assessing the seriousness of adolescent drug abuse (ASADA) scoring

method. 100

APPENDIX IX: Paediatrics Symptoms Checklist (PSC) – Youth report version 101

APPENDIX X: School data/ report 103

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DEDICATION

To my ever loving and supportive husband CHUKWUEMEKA,

With whom I have these 6 lovely daughters,

Thank you for enduring till the very end of this program.

You Inspire Me.

I LOVE YOU.

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ACKNOWLEDGEMENTS.

I express my heartfelt appreciation to my supervisors, Prof N C Ojinnaka, and Dr

R.C Ibekwe for painstakingly guiding me through my research work and manuscript writing.

Your constructive criticisms and patient guidance helped me perfect this work.

I thank all my teachers for guiding me through the various stages of residency

training. I will continue to make you proud. I also appreciate Mrs G C Ngwu of the Ministry

of Education Ebonyi State and the authorities of the various schools used for this study

whose approval made this work possible.

I appreciate Dr L U Ogbonnaya (Professor of Community Medicine), and his wife,

Dr C.E Ogbonnaya both of whom made my residency training dream come true. To my

father Eze (Dr) E.O Nwigwe, and mother Prof H.C Nwigwe (Ugoeze), I'm eternally grateful

for your support all through my stay here in Abakaliki. My siblings Obiyo, Chinenye, and

Munachiso, your individual encouragement have helped me all the way.

I appreciate my lovely daughters Hadassah, Shalom, Tehilah, Nagge, and my twins

Orna and Rinnah who had to endure the burden of being without their mother so many times

because mummy had to work and study. Your prayers kept me strong at my lowest moments.

Above all I thank God Almighty for being my source of strength all through the

training.

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SUMMARY

Academic performance of students may be influenced by substance abuse. Substance

abuse could result in increased school absence while increasing predisposition to behavioral

disorders which may result in poor concentration thereby hindering the abuser from

benefiting from schooling. Poor academic performance undermines efforts made by parents

and teachers to impart knowledge on students in a bid to improve their future income

capabilities.

Six hundred and twenty senior secondary 2 and 3 students selected in a multi-staged

manner were screened for substance abuse using the WHO students’ drug use questionnaire.

Academic performance, school absence, psychosocial impairment of substance abusing

students was compared with those of their classmates matched for age, sex and socio-

economic class.

Prevalence rate of substance abuse obtained was 32.9% and alcohol was the most

commonly abused substance. There was a general poor academic performance of students

although the academic performance of substance abusing students(67.3%) was significantly

(p<0.001) poorer than that of control(35.8%). Substance abusers also had lower scores in the

four subjects studied (biology, English, Igbo and mathematics) when their scores were

compared with non-substance abusing students. There was also higher mean number of days

absent from school (14.68+4.79 for subjects; 9.50+3.84 days for controls; p<0.001) as well as

a higher prevalence of psychosocial dysfunction amongst substance abusers (43.7% of

subjects against 13.9% of controls). Age at initiation of substance (p=0.006) as well as use of

multiple substances (p=0.003), were the most important determinants of academic

performance of substance abusers. However, school absenteeism (p<0.001) was the

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underlying determinant of academic performance of all students whether substance abusing

or non-substance abusing.

It is concluded that substance abuse is high among secondary school students in

Abakaliki and that the academic performance of substance abusers is poorer than that of

those who do not abuse substances. It is therefore recommended that substance abuse and

school absenteeism should be considered in students with poor academic performance in

senior secondary schools in Abakaliki.

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INTRODUCTION

Substance abuse is a complex behavior seen amongst young people all over the

world.1 Reports from epidemiological studies in Nigeria,2-4 Ghana,5 South Africa,6,7 Kenya,8

and the United States 9 have shown alarming figures of substance abuse among young people.

Abuse of substance is now recognized as a significant public health problem worldwide.10

Adolescence which is defined by World Health Organization (WHO)11 as the age

between 10-19 years, is characterized by increased adventurous tendencies and peer

influences.12 During this period, children establish their individuality and become

independent. They tend to form gangs, and are often seen 'hanging' around with peers

experimenting with new things including the use of substance.13 Young people often start by

taking ‘gateway’ substances like cigarette and alcohol from which they gradually progress to

other substances to degrees that control their behavior.14

Previous authors13,15,16 have identified some reasons for the use of substances by

adolescents. These include curiosity, suppression of anxiety or mustering courage to speak to

the opposite sex, a way of fitting into the desired gang or social clubs, and as a means to

feeling ‘high’ at all times. Other reported reasons include availability of substances, parental

influence, as children from homes where parents take substances are often more likely to do

the same. Kola nut and coffee are often consumed to keep awake during examinations.15,16

Adolescents’ who abuse substances are exposed to risks and consequences that can

manifest physically, psychosocially and behaviorally.17 For instance, the abuse of

psychoactive substances is known to increase the incidence of psychosocial disorders in the

adolescent.17,18 In addition, drunkenness, risky sexual behavior and other delinquent behavior

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like stealing and running away from home have also been reported amongst substance

abusers.19,20

Several authors21-23especially in the developed countries have noted poor school

performance in adolescents who abuse substances. Such students have been reported to have

declining school grades, dropping out of school and impaired concentration, memory and

thinking.21-23 It has also been found that college students who used marijuana regularly had

impaired skills related to memory, attention and learning 24 hours after using the substance.24

Furthermore deficits in mathematical skills, verbal expression, as well as selective

impairments in memory-retrieval processes were observed in those who used marijuana

seven or more times weekly.24 Lukoye et al25 reported poor academic performance amongst

4.4% of first year university students in Kenya who abuse cigarette. Similarly, Cox et al26 in

a survey of academic performance and substance use among public high school students

noted low academic performance in those that drunk heavily, smoked frequently and used

marijuana. The authors26 adjudged participants who had mostly grade-C and below as having

low academic performance.

Academic performance of an adolescent affects the individual as well as the society at

large. Poor academic performance may frustrate a student and lead to dropout on the short-

term while affecting the individual’s future occupational prospects.27 Poor performance

academically of a large group of adolescents, affects the society by increasing unemployment

and reducing the development of human capital, while undermining the mission of investing

in schooling.27

Abakaliki, the capital of Ebonyi state in South Eastern Nigeria is an emerging city.

People migrate from the rural to the urban center. A prevalence of 27.1% was observed as the

rate of adolescent substance abuse in an earlier study in Abakaliki.30 There has been empirical

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observation of increasing crime rate such as rape and armed robbery, majority of the culprits

were young adolescents who should be in secondary schools. Studies have shown that such

crimes and behaviors may be associated with substance abuse.19,20,28 The government of

Ebonyi state has tried to encourage literacy in the populace by introducing the Universal

Basic Education (UBE) scheme and improving the states of boarding facilities in secondary

schools so that students can have conducive environments for studying to improve their

performance academically. However, students have performed poorly at recent exit external

examinations, West Africa School Certificate (WASC) exams and the National Examination

Council’s (NECO) exams. Less than 30% of students who took these exams achieved the five

credits with English language and mathematics inclusive required for entrance into higher

institutions in Nigeria.29 Many reasons have been postulated as being responsible for this

worrying academic trend, one of which is the high prevalence of substance abuse reported

among adolescents in Abakaliki.30 This association is anecdotal, there has been no study to

test this hypothesis. This study aims at establishing the pattern of substance abuse amongst

secondary school students in Abakaliki and the academic performance of such substance

abusing students. It also hopes to determine if there is any association between substance

abuse and the academic achievement of these students.

JUSTIFICATION

The school is a place where young people gather to learn. In schools students not only

receive the instructions given during each subject, they also learn to interact with each other.

Peer pressure and the need to belong to a certain group of friends arise in schools especially

in the period of adolescence. Most substance abusers were introduced to it by friends at

school.30-32 This makes the school a good site for the study of substance abuse.

Substance abuse is an increasing problem amongst youths in Nigeria and the world at

large. Data from school surveys in Nigeria have shown a rising prevalence and a decreasing

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age at onset of substance use.33-36 Other studies have shown not just a rise in consumption,

but also increasing female involvement and a trend towards multiple substance use among

Nigerian adolescents.33,34 Substance abuse has negative effects on the user’s physical, mental,

behavioral and emotional health which may affect performances in school.

Academic performance of students may be influenced by substance abuse since

substance use could result in poor concentration, memory loss and absences from studies.

Poor academic performance undermines the efforts parents and teachers put into imparting

knowledge on students while frustrating the student and may lead to school dropout. Also,

failing to achieve good grades in school could be a pointer to delinquent behavior in

adolescents who abuse substances. Although there is a high prevalence of substance abuse

among secondary school students in Abakaliki, 30 there has been no report on the academic

performance of such students. The absence of any study describing the academic performance

of such students in Abakaliki and the factors influencing their academic performance justifies

the study.

This study aims not only at adding to existing data on the prevalence and factors

associated with substance abuse among secondary school students, but also to describe the

academic performance of such substance abusing adolescents with the aim of forming the

basis for policies for their educational program.

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LITERATURE REVIEW

Definitions of Substance Abuse

A substance is any chemical agent other than food which affects a living organism.37

These agents interact with the body system to modify its physiological and biological

processes.38 Odejide39 and Obianwu40 both defined substances as agents that act mainly on

the brain and affect psychological function resulting in effects such as sedation, stimulation

and change in mood or behavior. Substances also possess the potential for habit

formation.39,40

Substance abuse as defined by the World Health Organization Expert committee on

Drug Dependence is the persistent or sporadic excessive substance use inconsistent with or

unrelated to acceptable medical practice.41 By this definition, intentional use of large

quantities and the intentional use of therapeutic doses for purposes other than that for which

the drug is indicated are inclusive. The terms, misuse and non-medical use were used

synonymously with abuse in this definition.41 This definition however, includes all

pharmaceutical agents and not just psychoactive substances. Abiodun42 defined substance

abuse as taking a substance which harms or threatens to harm the physical or mental health of

an individual or the society at large. The author42 opined that the effect of substance use was

not just on the individual but involved the society. Odejide39 on the other hand, defined

substance abuse as the use of agents, when they are not medically indicated, when they are

used against legal prohibition or when there is an excessive use of socially acceptable

substances such as tobacco and alcohol. These socially acceptable substances were termed

licit while the legally prohibited substances were termed illicit substances.43 In addition,

Obot44 defined substance use as consumption, in any form, of a substance to alter mood or

behavior, and that when a substance is used beyond culturally accepted limits it becomes

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abuse. This supposes that substance use and abuse are stages of a process with abuse being a

severe form of substance use. Furthermore, Burns45 defined substance abuse as a pathological

pattern of use of a substance, characterized by the inability to control its use resulting in

impairment in social and occupational functioning with the duration of abuse being at least

one month. Ebie and Ebie38 brought in the aspect of society, by defining substance abuse as

the use of a substance viewed by the society concerned as posing a problem. The authors38

suppose that a person is termed as abusing a substance only if it poses a problem to the

society.

History of Adolescent Substance Abuse in Nigeria

Cannabis, in the form of marijuana or Indian hemp leaves, was the first illicit drug of

abuse in Nigeria.46 It was introduced into Nigeria by sailors and retiring soldiers returning

from the Middle East and North Africa during and after the Second World War.47 The abuse

of cannabis was first noticed in 1960, and in 1966, the Indian hemp Decree was promulgated

to control the wide spread use of the substance.47 By the 1970’s and early 80’s the abuse of

alcohol and other prescribed drugs by young people came to the forefront.46 In the early

1980’s cocaine and heroin were introduced to the scene as the country became a trans-

shipment route for drugs meant for Europe and America.48 Since then, urbanization, with the

adoption of the western life-style, in addition to increased availability and affordability of

substances have contributed to the shifts in the pattern and types of substances abused in

Nigeria.16,31

Scope and Prevalence of Adolescence Substance Abuse

Alcohol

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Alcohol is a substance of dependence which is produced by fermentation, a process

which turns sugar into ethanol.39 Alcoholic beverages abound in Nigeria, from the traditional

drinks such as palm wine (the sap of either the oil or raffia palm tree), burukutu (produced by

fermentation of millet) and ogogoro (a gin-like distillate of palm wine) to the western types

such as beer, rum and gin introduced to Nigeria by Europeans.39,49 Since the advent of the

Europeans, beer has become the most popular type of alcoholic beverage in Nigeria and has

resulted to an increase in the number of breweries in Nigeria.36 Furthermore, the availability

of alcoholic beverages has made its consumption common especially amongst adolescents in

secondary schools. It was consumed more by males than females, however authors38 have

observed that the difference in prevalence rates of alcohol consumption between males and

females is narrowing.

Epidemiological studies33,34 have shown alcohol as the most commonly abused

substance. This is because it is readily available and can be easily accessed by adolescents. In

Enugu South Eastern Nigeria, Igwe et al50 working amongst secondary school students in

SS2 and SS3 showed that 31.6% of respondents currently used alcohol, majority of whom

were males (67.3%). In contrary, 12% of senior secondary students were reported to abuse

alcohol in Ilorin, Middle belt Nigeria.51 On the other hand, Odejide and Olatawura32 in

Western Nigeria reported an abuse rate of 9% in a rural community, while Anochie et al52

reported that 36.4% of secondary school students in Port Harcourt, had tried alcohol at least

once. The authors52 also reported that, 12% of their participants were currently using it on a

regular basis. The varied prevalence rate may be attributed to the differing case definitions

used by the different authors as well as cultural behaviors in different localities. While Igwe

et al50 and Anochie et al52 studied current alcohol use and obtained higher figures, Abiodun et

al51 and Odejide and Olatawura32 studied those whose current use of alcohol was to such a

degree as can be adjudged abuse, and hence obtained lower prevalence rates. Cultural

24

practices may also contribute as some tribes in Rivers state introduce alcohol to their

newborn and young children. It is also worthy of note that the study by Odejide and

Olatawura32 was conducted in a rural community where limitations of access exists to alcohol

use. The low rate of 9%, reported may be due to strong cultural inhibitions which may have

resulted in actual low prevalence rates, and or to under-reporting. All except the study by

Anochie et al52 showed male preponderance in alcohol abuse. This observation may be due to

the fact that Port Harcourt is a highly industrialized city which supposes that there may be an

increased availability of alcohol to both males and females alike. Alcohol acts primarily as a

central nervous system depressant resulting in euphoria, talkativeness, impaired short-term

memory and reduced inhibition.53

Cannabis

Cannabis is a mind altering substance made from a plant called cannabis sativa which

thrives in both temperate, and tropical climates including Nigeria.53 It has many street names

in Nigeria such as weewee, ganja, grass, daga, bang, hashish, charas, stone, kaya, pot, weed,

igbo, morocco and Indian hemp amongst others.54

Several authors50,55,56 have reported variable prevalence rates of cannabis abuse

amongst secondary school students in Nigeria. Igwe et al50 reported cannabis abuse rate of

4.1% in senior secondary school students in Enugu South Eastern Nigeria and noted that

cannabis was used exclusively by males. In Port Harcourt, Southern Nigeria, Anochie and

Nkanginieme2 reported that amongst secondary school students, 3.6% of males,and 2.2% of

female participants were current abusers of cannabis. Similarly, Oshodi and Aina55 in Lagos,

Western Nigeria, reported cannabis abuse rate of 4.4% amongst secondary school students.

The authors55 report however, was of those who had ever used cannabis in their lifetime and

did not bring into cognizance those who were currently using the substance suggesting that

25

the actual prevalence of cannabis abuse in their population may have been lower than they

reported. Males also had a higher lifetime use of this substance in the study.55 Furthermore,

Shehu and Idris56 working in Zaria, Northern Nigeria reported cannabis abuse rate of 9.4%

among secondary school students with 90% of them being males. The reported low

prevalence rates of cannabis abuse may represent its true prevalence or may be attributable to

denial since cannabis use is prohibited by law. This supports the postulation of Fatoye and

Morakinyo34 who observed that there remained a low reported prevalence rate of cannabis

use among secondary school students in Nigeria in spite of the high cannabis-related

psychiatric disorders observed amongst students in Nigerian psychiatric clinics. This they

attributed to denial because of the legal consequences associated with cannabis use.

Cannabis contains tetrahydrocannabinol which exerts its effect on the central nervous

system (CNS) to produce euphoria, loss of inhibition, hallucinations, reduced concentration,

feeling of relaxation and sleepiness.31,39

Tobacco

Tobacco is derived from a plant named nicotiana tabacum which was cultivated for

its medicinal and mystical uses in the 14th century.34 Recently the use of tobacco has changed

from its use for mystical reasons to consumption in the form of cigarette, cigar, pipe tobacco,

chewing tobacco and the traditional snuff.30 Cigarette smoking has become the most favored

form of tobacco use in Nigeria while snuffing remains popular in the rural areas amongst

older persons.30

Advertisements and promotion of sporting, cultural and social activities by cigarette

manufacturing companies have increased the rate of cigarette smoking.36 Nigerian studies2-

4,16,50,52 have revealed a high prevalence rate of cigarette smoking among secondary school

boys and girls. Igwe et al50 reported that 14.3% of senior secondary school students in Enugu,

26

South Eastern Nigeria currently used cigarette. In their study50 all respondents who used

cigarettes were males. This report is remarkably higher than that documented by Anochie et

al52 in Port Harcourt metropolis where a prevalence rate of 2.7% was reported and higher also

than the 6.4% prevalence reported by Odey et al57 in Calabar South East Nigeria. These later

studies52,57 not only reported current cigarette use rather, their report was on the participants

who currently used cigarette excessively and had tried but were unable to stop cigarette use

which defines abuse. Salawu et al58 on the other hand studied adolescents aged between 12

and 17 years in communities in Yola, Adamawa state Northern Nigeria and reported a

prevalence of 33.6%. Their study58 was carried out on adolescents randomly selected from

the market area. It is worthy of note that their participants were out of school, reasons for

being out of school, and at the market area instead were unknown to the researchers. This

therefore, may have accounted for the remarkably high prevalence rate for cigarette use.

Cigarette smoking has been associated with so many illnesses like lung cancer, stroke,

heart disease and chronic lung diseases like emphysema. Those who chew tobacco have been

reported to have an increased risk of oropharyngeal carcinoma in adulthood.53

Coffee

Coffee is a substance that is derived from a shrub coffee canephora which grows in

different parts of the world including Southern Nigeria.30 Its active ingredient, caffeine is a

central nervous system stimulant which causes increased alertness and decreased sleepiness

by increasing the release of cathecolamines.59,60 This effect on arousal has made coffee abuse

very common amongst adolescents in schools especially during preparation for examinations.

Despite its beneficial effect on arousal and decreasing sleep, caffeine use has been associated

with poor learning.61 Mednick et al61 conducted a study to compare the use of caffeine,

having some daytime sleep (“nap”) and a placebo on verbal, motor and perceptual memory.

27

The authors61 observed that moderate dosage of caffeine impairs motor skill and may not be

an adequate substitute for memory enhancements or daytime sleep. This effect is due to

caffeine induced increase in hippocampal acetylcholine which may have negative effects on

cognition, perceptive memory and learning. Wentz and Magavi60 on the other hand,

demonstrated that caffeine depressed hippocampal neurogenesis by observing this effect

when administering high doses of caffeine into mice.

Igwe et al50 reported a current use prevalence of 20.7% among secondary school

students in Enugu Nigeria. More males abused coffee and more students in SS3 abused

coffee. The authors50 attributed the high prevalence to the fact that these students were

preparing for exams and used kola and coffee as stimulant to stay awake at night. Contrary to

the previous report, Abdulkarim et al62 in Ilorin, Southwest Nigeria, reported a combined

prevalence of 26.2% for coffee and kola nut abuse amongst students aged 10-19 years in

secondary schools. The authors62 found no gender disparity in the prevalence rates in this

study and students enrolled for the study were in both junior and senior secondary schools

and were probably not involved in active preparation for exams.

Kola nut

Kola nut is derived from the plant cola nitida which is found in West Africa. It is

shared traditionally in several Nigerian cultures as a sign of hospitality.39 Kola nut is also

used by the poor to ward-off pangs of hunger and by students to keep awake when preparing

for exams.39 Its active ingredient is caffeine.

The prevalence of Kola nut abuse by secondary school students in Nigeria was

reported as 13.3% amongst students aged 10-18 years in Enugu, Nigeria by Okwaraji.4 On the

other hand, Okonkwo et al47 had reported a prevalence rate of 16% for coffee and kola nut

abuse put together. While Okwaraji13 used a self-constructed questionnaire for his study on

28

substance abuse, Okonkwo et al47 had used the modified WHO questionnaire for students

drug use. Moreover, Okwaraji's study may be a better representation of Enugu since he

studied a total of five schools while Okonkwo’s participants were selected from a single

school. As with other substances, both studies showed a male preponderance in the use of

kola nut. Abdulkarim et al62 also reported a higher combined rate for coffee and kola of 26%

in Ilorin. The difference between the reported prevalence in Enugu and Ilorin may be

attributed to the availability of the substance and cultural variations in the two locales.

Though the Igbos of Southeast Nigeria use kola nut for traditional purposes, kolanut is

planted and produced in Western Nigeria, it is thus more affordable and accessible to

adolescents in Western Nigeria. The effect of kola nut use is similar to that of coffee since

they have similar active agent.

Cocaine

Cocaine is an alkaloid derived from the coca plant.53 It is usually supplied as the

hydrochloride salt which can be snorted or dissolved in water and injected intravenously.53 It

is primarily a stimulant giving the user a ‘high’ feeling after its use.

Three decades ago cocaine abuse was not heard of in Nigeria until the explosion of

drug trafficking in the 1980’s.46 However surveys still report minimal prevalence rates

probably due to denial since it is illegal. Fatoye35 in his study of five hundred and sixty two

senior secondary school students in Ilorin reported a cocaine abuse rate of 0.2% with a male

preponderance in its abuse. On the other hand, Abdulkarim et al62 reported a remarkably

higher prevalence rate of 3.6% amongst adolescent students in a recent study in the same

area. Although a similar finding of male preponderance in cocaine abuse was observed, the

huge difference in prevalence of both studies may reflect changing societal trend with

increasing availability and affordability of this substance. In Port Harcourt Southern Nigeria,

29

Anochie and Nkanginieme52 reported a prevalence rate of 2.2% and 0.7% amongst male and

female senior secondary 3(SS3) students. It is plausible that the reported low prevalence rates

of cocaine abuse may be “apparent” rather than “real” because of under-reporting due to

denial since cocaine is an illicit drug in Nigeria.

Stages and Seriousness of Substance Abuse in Adolescents

Substance use in adolescents has been studied and found to occur in an increasing

manner.63 Adolescents, usually start with licit substances like alcohol and cigarette and

progress to cannabis use which in turn leads to the use of other illicit substances.63 Cormerci

and Schwebel64 defined various stages of adolescent use of alcohol and other substances

which are;

Experimentation is the use of socially acceptable substances minimally, for instance

use at social outings;

Recreational is the progression to illicit substances like cannabis;

Problematic is regular substance use leading to personality changes associated with

difficulties at home and at school;

Compulsive is the final stage, where the individual is truly addicted with need to avoid

abstinence effects.

Factors Influencing Substance Abuse

Initiation into substance use and progression to abuse is influenced by the complex

interaction of the pharmacologic effects of the drug, its availability, the personality of the

user and the environment in which the substance is used.44 Studies have identified such

factors as economic hardship, unemployment, failed relationships and poor academic

attainment as contributing factors. 36,51,52 Substance use amongst adolescents have been

30

linked to their exploratory behavior which is part of their development.53 Other contributing

factors identified by previous authors were peer influence,4,15,51 advertisements that

encourage the use of these substances15,36 urbanization and migration.36 Family structure and

parental influence is also contributory.36 Previous authors have reported a higher prevalence

rate of substance abuse amongst students from divorced homes, those who had lost their

parents or those who had strained relationships with their parents.4,15,31 The finding may be

attributed to lack of parental supervision and discipline. Parental use of substances has also

been identified as a risk factor for substance use by adolescents36 as the availability of the

substances and observation of their parents may result in trial of substances and ultimately

abuse in adolescents.

Although both gender are reported to be involved with substance abuse, it is said to be

more common among the male gender because of their more adventurous nature.2,4,16

Additionally, adolescents who engage in substance abuse have been found to have

commenced the use of substances in their early teens due to increased peer pressure in early

adolescence.4,36,47-49

Consequences of Substance Abuse

Substance abuse has consequences on the individual. The adolescent who abuses

substances is at risk of physical, psychological and social consequences. He or she

experiences acute physical problems like central nervous system stimulation resulting in

restlessness, seizures, cerebral hemorrhage, insomnia, fainting attacks from hypoglycemia

and irritant cough from cocaine and cannabis use.31,39 Psychological problems such as

hallucinations, poor perception, illusions and delusions have been linked with cannabis

use.31,39 Alcohol abuse has also been associated with other psychological problems such as

deterioration of personality, blackout, morbid jealousy, and hallucinations.65,66 Social

31

consequences of substance abuse include delinquency, risky sexual behavior, drunkenness

and poor school performance.31,39

Academic Performance and Substance Abuse.

Academic performance is the extent to which a student achieves his or her educational

goal.67 It is usually measured by performances in school examinations and continuous

assessment.67 Students substance use have been shown to be a risk factor for academic

problems such as lower school grades, absenteeism and high dropout rates.68 Alcohol for

instance interferes with a student’s ability to think making learning and concentration more

difficult. The more alcohol a student uses the lower his grade point average and the more

likely he is to drop out of school.68

Cox et al26 in a survey of academic performance and substance use among public

high school students in USA, noted low academic performance in those that abused alcohol,

cigarette, or marijuana. They defined poor academic performance as having a grade C or

below. The authors26 studied academic performance in mathematics and Spanish language

and assessment was made using school records. Similarly, Ingles et al69 using the same

measure for assessment of academic performance in grade 8-10 students, reported poor

academic performance in adolescents who abused alcohol or smoked daily probably because

their interest is not positioned on school achievement or because consumption of substances

interferes with their study tasks. Lukoye et al25 in Eldoret, Western Kenya, reported poor

academic performance evidenced by a low grade point average in 4.4% of first year

university students in Kenya who abuse cigarette. However, self-rating of academic

performance was used by the respondents with the tendency of under assessment with this

method. Substances has been shown to have varying effects on the central nervous system

which can decrease cognition generally.16,21-24,39,53,60 Those who abuse substances have been

32

shown to manifest other delinquent behavioral attitudes such as truancy which has been

shown to affect academic performance.20-22,70

In a study carried out by Fatoye,35 amongst Nigerian senior secondary school students

in Ilesha, Osun state, poor academic performance was reported in participants who used

coffee and tobacco. Academic performance was assessed using the respondents self-rating of

his/her performance. This method of assessing academic performance may be unreliable and

non-reproducible as it relies largely on own perception of academic performance. A similar

finding of poor academic performance was made of secondary school students who abused

marijuana when compared to controls in Zaria Northern Nigeria by Shehu and Idris.56 The

authors56 assessed academic performance using class positions of subjects and controls which

is relative to the academic performances of the other students in the class and so not reliable

such that a subject with 70% average may be the first position in one class but may take the

last position in a more competitive class.

Varying mechanisms by which substance abuse may result in poor academic

performance have been postulated by different authors.21-24 One mechanism being that

substance use itself may have a direct effect on cognitive development which results in

academic under achievement and disruption of academic progress.21-24 Studies22-24 have

shown that heavy substance use can lead to problems in working memory and attention due

to changes in adolescent brain activity. This results in poor academic performance and

engagement in school, ultimately increasing the risk for school problems and dropout.

Alternatively, substance use during adolescence leads to association with antisocial

peer groups which diminish school engagement while increasing other behavioral and social

problems resulting in school absences and decreased motivation to attend school.71 Langas et

al72 in Norway, reported that 46% of first admission substance use patients in the

33

neuropsychiatric ward had at least one personality disorder. Those who had personality

disorders were younger at initiation of substance use, used more illicit substances, and less

often attended school.72 Although the study was done in an adult population, subjects had

become abusers of substances in their adolescence. Similarly, Igwe and Ojinnaka73 in

Nigeria, reported a higher prevalence of psychosocial disorders amongst substance abusing

adolescents when compared to controls, however his study employed the definition of current

use of substances. Other authors have also collaborated increased delinquent behavioral

attitudes which can affect academic performance in substance abusers.20-22

Factors Influencing Academic Performance in Substance Abusers

Students’ academic performance is a product of several socioeconomic, psychological

and environmental factors.67 A student's natural ability, his/her motivation, and the quality of

primary education obtained may go a long way in determining how he/she performs in

subsequent levels of education.70

Various factors may contribute to the academic performance of substance abusers

irrespective of their natural abilities and motivation.71 The detrimental effect of substance use

has been supported by reports that maturation of the brain is not complete until after

adolescence.71 Therefore, increased use of various substances can cause injury to the

immature brain thereby resulting in reduced intelligence and poor school performance.71

Gender.

Athough previous authors have reported higher prevalence rates of substance abuse in

males more than occurs in females2,4,16,50 which may be due to the more adventurous nature

of boys, the association between gender and academic performance is yet to be explored.

34

Socioeconomic class.

Socioeconomic class has been found to be an important factor in substance abuse.30

Authors have reported a higher prevalence of substance abuse among the lower and middle

socioeconomic classes.30,50,74 This finding was attributed to permissive attitude of parents to

the use of these substances. It may also be due to poor supervision by the parents of these

adolescent substance abusers. However, Anochie et al2 reported that there was no significant

correlation between substance abuse and social class. It is noteworthy that in a highly

commercial city of Nigeria, Port Harcourt, substances are readily available to adolescents of

all socioeconomic classes so that there is no difference in prevalence rates of abuse of

substances in the different socioeconomic classes.

Academic performance however, has been reported to be poor in the lower social

class and students from the lower social class were more likely to drop out of school.75 Some

authors75-77 believe that low social class negatively affects academic performance because it

prevents access to vital resources and creates additional stress at home. The economic

hardship caused by low social class leads to conflicts in the home which results in a poor

quality of home life for these children. On the contrary, children from higher social class

generally have a more favorable learning environment with access to extra learning facilities

which aids their performances in school, their parents are more likely to be more educated

hence there is a better supervision of their school work.75-77

Psychosocial impairment.

Substance abuse has been linked with various deviant behaviors which could affect

academic performance negatively.71 Alcohol abuse is associated with depression, anxiety and

personality deterioration.65 Students who abuse substances are more likely to be involved in

other social vices such as stealing and truancy which has been linked to psychosocial

35

impairment.19,20,28 Psychosocial impairment in substance abusers make them lose

concentration during lessons and assessments making their overall academic performance

poor.71 Gruber et al78 found an increased prevalence of inattention in heavy substance

abusers. Their study of 129 American students found that, heavy marijuana users (those who

used the substance at least 27 of the preceding 30 days), lacked critical skills related to

attention, memory, and learning was significantly impaired, even after they had not used the

drug for at least 24 hours. The heavy marijuana users in the study had more trouble sustaining

and /or shifting their attention, as well as in registering, organizing, and using information

than did the study participants who had used marijuana no more than 3 of the previous 30

days.78 Heavy smokers of cannabis were more fidgety and had more records of truancy much

more than those who were not smokers of canabis.78 Langas et al72 also reported that 46% of

their subjects who used substances had personality disorders which was more associated to

the age at the initiation of substance use.

School absenteeism

School absenteeism has been associated with poor academic performance because

students who are absent at lessons miss out on the daily class lessons.79 Substance abusers

often indulge in risky behaviors including truancy in school.70 Truants ‘hang out’ with peers

rather than sit in class for lessons. In doing so, they lose interest in schooling which could

finally result in school drop-out. Okike,30 found school absenteeism as one of the

consequences of cigarette, alcohol and cannabis abuse in Abakaliki South eastern Nigeria.

The author30 inferred that the centrally acting substances may produce ''hang over'' effects on

the abusers, thereby making school attendance difficult. Okike30 also postulated that since the

abuse of substances leads to impaired concentration, the abusers may decide to stay away

from school to avoid the embarrassment their poor concentration in school might cause them.

Although increased school absences has been reported in substance abusers, there has been

36

no report of the relationship between school absences and academic performance in substance

abusers.

Severity of substance abuse

Severity of substance use may also affect the academic performance of substance

abusers. Cormerci and Schwebel64 defined various stages of adolescent use of alcohol and

other substances. At initial stages of experimental and recreational use there may be little

symptomatology of substance use disorders. Later on, in the problematic and compulsive

stages, the adolescent experiences difficulties at school and at home. These difficulties may

affect their performance in class work.64

Instruments for Assessing Substance use and abuse

The objectivity of detecting recent substance use by urine testing in adolescents is

undisputed, however this does not provide information about the adolescent's history of

substance use problems. More over some substances require quick assessment in order to

detect it in the urine, like alcohol whose evidence of use in urine disappears after eight

hours.80 It therefore supposes that self-report, especially when confidentiality is ensured and

no legal contingency is attached, in describing pattern and factors affecting substance use and

abuse is reliable.65 Studies carried out with self-report are cheap, easily accepted and the

refusal rate has been found to be minimal.81 Various instruments of self-report have been used

to study substance abuse. The cutting down, annoyance by criticism, guilty feeling and eye-

opener’s (CAGE) questionnaire82 is one of such instruments which has been used for

screening of alcoholism and has been validated for use in American Indian population by

Saremi et al.83 It consists of a set of four questions for which scores are given for a yes (score

1) or a no ( score 0) answer. A total score of two or above is significant in diagnosing alcohol

abuse. This questionnaire is strictly for alcoholism, however some authors have modified it to

37

study the abuse of other substances. Other instruments used are; the car, relax, alone, friends,

forget, trouble (CRAFFT) questionnaire, Adolescent drinking index (ADI) and the Personal

experience screening questionnaire (PESQ).80 These instruments are culture specific and have

not been validated for use in Nigeria. Self-constructed questionnaires have also been used in

the study of substance abuse,84 which has resulted in a wide variation in prevalence rates of

substance abuse reported.

It is based on this that the WHO81 constructed a questionnaire for students’ drug use

which can be used in epidemiological studies of substance abuse. The WHO student’s drug

use questionnaire consists of two sections. The first describes the socio-demography of the

respondent such as age and sex. Parental education has been added as a modification by

Nigerian authors to aid in establishing the socioeconomic class of respondents.30,73 The 2nd

section describes the use of various substances in the past 30 days (current users), before the

past 1year (past use) and ever in their lifetime (lifetime use). Other questions try to evaluate

who introduced the respondent to substance use, age at first use of a substance and attempts

made at stopping substance use. A ''yes'' to the question ''have you ever tried to stop the use of

this substance and found that you were unable to'' signifies an addiction to the substance

hence its abuse. Current use of illicit substances which is included in the WHO questionnaire

was also considered as abuse as defined by Odejide et al.39 Several modifications can be

made to the questionnaire to suit the cultural differences in different countries such as

introducing local names of the substances like "ogogoro" which was used for alcohol in the

study by Okike.30 The author30 also introduced a fictitious substance "flexinal" which `was

used to check over-reporting of abuse of substances. The advantage of the WHO

questionnaire is that it can be completed within 30 minutes. The questionnaire also brings

standards and makes the study reproducible. Hence studies within and outside a country can

be compared making planning for educational and treatment program for drug users easier.

38

On the other hand its disadvantage is that a lot of expertise is required in the analysis of data

collected by it because it has 30 or more items in the questionnaire. However, this can be

circumvented by using statistical packages like the statistical package for social sciences

(SPSS) and a well-trained biostatistician. This questionnaire has been further revalidated for

use in Nigeria85 and has since been used by several authors on substance abuse in

Nigeria.30,33,34,73

Assessment of Severity of Substance Abuse.

The Addiction Severity Index (ASI) is a structured interview designed to provide

important information or screen for problems in individuals who abuse substances.86 It

contains questions which try to explain certain problem areas. Such areas are interpersonal

difficulties with family, friends, and co-workers; medical conditions such as hepatitis B,

HIV/AIDS, sexually transmitted diseases, alcoholic liver disease, acute myocardial

infarction, pneumonia, metabolic and endocrine complications; and legal problems. It uses

questions in the different subscales, interpersonal difficulties, medical problems, and legal

problems of people who abuse substances. The questionnaire requires about 60 minutes to

administer and describes the seriousness of the individual’s substance abuse problem by

determining the degree of complications of substance abuse such as the presence of

interpersonal and legal problems. The coexistence of medical problems with substance use

also worsens the individual’s clinical state. The ASI has been used extensively for planning

of treatment and evaluation of the outcome of treatments for substance use disorders, but

because it also deals with other problem areas aforementioned it is cumbersome to

administer. It also requires that the researcher personally interviews each individual using the

questions.

39

Other instruments used in assessing seriousness of substance abuse disorder are,

Composite International Diagnostic Interview (CIDI), Structured Clinical Interview for

DSM-IV (SCID), Alcohol Use Disorders and Associated Disabilities Interview Schedule

(AUDADIS), Psychiatric Research Interview for Substance and Mental Disorders (PRISM),

and Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA).68 These

instruments have been tested and found valid and reliable in assessing seriousness of

substance abuse however they all require between 60 and 90 minutes to administer and

require lots of training to use. They are also culture specific and have not been used in

Nigerian studies.

Assessing the seriousness of adolescent drug abuse (ASADA) score53 is an

instrument for assessing the seriousness of substance use. ASADA questionnaire (see

Appendix 9) uses an aggregate of variables to assess the seriousness of students’ substance

abuse. Variables include type of drug used, setting of drug use, effect of drug use and use of

drug during driving. School performance, history of accident after drug use, time of week and

day of drug use and family history of drug use were also variables. Scoring is done by

assigning 0, 1 or 2 points for each selected variable and aggregate scores of 0-3, 4-8 and 9-18

are designated as less worrisome, serious, and very serious respectively. It is very easy to

administer and requires five to 10 minutes to complete hence can be used to assess

seriousness of substance abuse on a vast number of people at the same time. It has also been

used amongst Nigerian students.48 The ASADA questionnaire has its draw back being that the

self-report nature may introduce some bias since the truthfulness of reports may be

questionable. However, as with all other anonymous reports, it is believed that the reporter

will be truthful after he/she has understood the study and the need for a truthful response.

40

Instruments for Assessing Academic Performance

Academic achievement measures are standardized tests used to assess academic skills

of children.87 It is used to assess weather a condition or disease affects a child’s learning in

school.87 These measures include standard educational tests, like the Wide Range

Achievement Test (WRAT), the Peabody individual achievement test (PIAT), the

Woodcock–Johnson tests of achievement and the Schonnel attainment test, all of which are

curriculum based tests assessing the child’s performance in areas such as spelling, reading,

written language and mathematics.88 A student is problematic with these academic

achievement measures if he/she performs ≥1.5 standard deviation below age expectation on

either broad reading or broad mathematics measures.88 The advantage of these achievement

measures is that they are standardized tests, hence are reproducible. However, they are mostly

culture specific and are cumbersome to administer and assess. Moreover, none of these

academic achievement tools has been validated for use in Nigeria.

Academic attainment measures are direct measures of school performance that are

partially independent of formal testing situations.87 The school examination report is an

example of academic attainment measure.89 It involves the use of the sectional aggregate

score and scores in core, specific subjects like mathematics, English language, sciences and

social studies. This academic attainment measure was used by Ogunfowora et al89 in their

comparative studies of academic performance in children with sickle cell anemia. Ibekwe et

al90 also used the same methodology in assessing the academic performance of school

children with epilepsy. Using this attainment measure, a score <50% represents poor

academic performance. This measure has its disadvantage as being the lack of

standardization. Although the same subjects are being assessed, participants may have other

cofounders that may affect their scores in the individual subject such as having different

teachers. However since controls are selected from the same environment as the cases, it is

41

believed that both cases and controls are exposed to similar circumstances. In addition, this

measure of assessing academic performance is less cumbersome and has been used severally

by Nigerian authors.89-91

Other measures of assessing academic attainment include the school grade level

placement which has been found to correlate with IQ.88 However, the “social promotion” of

students, where a student is promoted despite the fact that he does not merit promotion, could

affect the accuracy of grade placement as an outcome measure.87

Assessment of Behavioral Problems.

Substance abuse has been associated with psychological and behavioral problems.

Some authors31,39,65,92-94 have described association between substance abuse and emotional

disturbances, anxiety, restlessness and chronic patterns of aggression, hostility defiance and

disruption all of which may affect academic performance.

A number of valid and reliable screening tools are available for assessing behavioral

problems in children and adolescents. These include the Strength and difficulty questionnaire

(SDQ),95 the School children problem scale (SCPS),96 the Rutter children’s behavior

questionnaire,97 the Conner’s comprehensive behavior rating scales (Conner’s CBRS),98 the

Paediatrics Symptoms Checklist(PSC)99 and the Child Behavior Checklist (CBCL).100

SDQ95 is a 25-item questionnaire that describes attributes of a child, including the

positive or negative attributes. It is divided between fives scales which describe emotional

symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and social

behavior. Two versions exist, the informant-rated version for parents or teachers of younger

children four to 10 years and another self-report version suitable for 11-17 year olds to fill

themselves. This rating scale has the advantage of being useful in both young and older

42

children and describes five domains of behavioral disorders, however it is cumbersome to

administer because it requires that a follow-up administration of questionnaire be done,

moreover it is culture specific and has not been validated for use in Nigerian children.

The Child Behavior Checklist (CBCL)101 has the youth self-report (YSR) and the

teacher report form (TRF). Although it is used by authors outside Nigeria, its use in Nigeria

has not been possible due to the fact that it has not been validated for use.

The Rutter scale97 is used to assess behavioral disorders in children and has been

validated for use in Nigerian children.101 This scale has also been used by other authors102

who assessed behavioral disorders in school children in Nigeria. This tool however, can only

be used for children aged four to 12 years.

Conner's CBRS rating scale98 is an instrument designed to provide a complete

overview of child and adolescent behaviors, emotions and academic problems. It is suitable

for ages six to 18 years (for the parent and teachers forms) and eight to 18 years (for the self-

report forms). It has the advantage of excellent reliability, validity and measures academic

difficulties in mathematics, language and total academic difficulties as well as aggressive

behaviors, separation fears, hyperactivity/impulsivity, social problems, perfectionist and

compulsive behaviors. However, it is a comprehensive tool which describes many disorders

and so cumbersome to administer. It is also culture specific and has not been validated for use

amongst Nigerian children and adolescents.

The PSC99 is a psychosocial screen designed to facilitate the recognition of cognitive,

emotional, and behavioral problems. Items in the questionnaire include questions based on

major diagnostic categories listed in the American Psychiatric Association Diagnostic and

Statistical Manual of Mental Disorders III (DSM-111).103 Two versions exist, the

parent‐completed version-PSC and the youth self-report‐PSC. The YSR‐PSC can be

43

administered to adolescents aged 11 and above. The PSC consists of 35 items that are rated as

“Never,” “Sometimes,” or “Often” present and scored 0, 1, and 2, respectively. The total

score is calculated by adding together the score for each of the 35 items. A cutoff score of 28

or higher indicates psychological impairment for children six years to adolescence. For

children aged two to five years, the scores on the items 6, 7, 14 and 15 are ignored and the

total score based on the remaining 31 items are used. The PSC cutoff score for the two to five

age group is 24 or higher. The PSC has been validated for use in general paediatric office

screening and its case classification has been correlated with the Child Behavior Checklist

(CBCL) of Achenbach and Edelbrock .104 Jellinek et al100 also reported its reliability and

consistency. The PSC had a specificity and sensitivity of 68% and 95% respectively with

clinician’s ratings.100 It has also been used to assess Nigerian adolescents73

AIMS AND OBJECTIVES

44

Aim

To describe the academic performance of substance abusing secondary school students in

Abakaliki.

Specific Objectives.

To determine the prevalence and pattern of substance abuse amongst secondary

school students in Abakaliki.

To identify the factors predisposing to substance abuse among the students.

To determine the academic performance of substance abusing secondary school

students and their non-substance abusing classmates.

To identify factors associated with academic performance of students abusing

substances.

MATERIALS AND METHODS

45

Study Area

Abakaliki is the capital city of Ebonyi state in the South eastern part of Nigeria. The

metropolis comprises parts of 2 Local Government Areas (LGAs) namely Abakaliki and

Ebonyi. The inhabitants are mainly Igbo-speaking though other ethnic groups are found. The

metropolis has a total population of 141,438 inhabitants according to the 2006 census

records.105 It’s inhabitants are of different educational attainment and religion. Majority of

them are farmers. There are a total of 13 approved secondary schools both public and

privately owned with about 5,748 students in SS2-3 in 2012/2013 session.106

Study Population

Students who were in SS2 and SS3 aged 10-19 years in the 13 secondary schools in

the metropolis constituted the study population for screening for substance abuse. This is

because they are the ones who are more likely to have abused substances for some time and

would have completed at least one session of senior secondary school. Subjects were those

that abuse substance while the control group consists of non-substance abusing classmates of

the subjects.

Study Design

It was a cross-sectional study.

Ethical Approval

Institutional ethical approval was obtained from the medical and ethics committee of

the Federal Teaching Hospital Abakaliki (see Appendix 1). Approval was also obtained from

the secondary education board of the state ministry of education, Ebonyi state (see Appendix

II). Similarly, informed written consent was also obtained from the Principals, selected

students and their parents/guardian before commencement of the study.

46

Inclusion Criteria

Students in SS2 and SS3 aged 10-19 years in the selected schools who were abusing

various substances.

Exclusion Criteria

Students less than 10 or more than 19 years of age.

Those who were unwilling to participate in the study were excluded.

Students with chronic diseases like sickle cell anemia, diabetes mellitus, epilepsy that

may affect a person’s academic performance as reported by previous studies.89-91

Sample Size

The desired sample size was determined in two stages. First, the sample size

appropriate for an infinite population (i.e. greater than 10,000) was calculated using the

formula107

n = z2pq/d2

where n = the desired sample size when the population is more than 10,000

z = the standard normal deviate, usually set at 1.96 (which corresponds to 95%

confidence interval)

p = the proportion in the target population estimated to have a particular characteristic

(prevalence of substance abuse amongst secondary school students in a previous study done

in Abakaliki Nigeria =27.1%).30

q = 1.0-p

47

d = degree of accuracy desired, which is usually set at 0.05

Substituting the values in the formula gives

n = (1.96)2(0.271)(0.729)

(0.05)2

=303.57708

However the target population is 5,748 which is the total number of students in SS2-3 in

Abakaliki. This population size is less than 10, 000, therefore the minimum sample size was

calculated using a correction formula 107

nf = n

1+ (n)

(N)

Where nf = minimum sample size for population less than 10,000

n = the desired sample size when the population is more than 10,000

Here n = 303.57708

N= the estimate of the population size which is 5748

Therefore,

nf = 303.57708

1+ (303.57708)

(5748)

= 303.57708

48

1.0528144

= 288.34815 ≈288.

Two hundred and eighty eight was the calculated minimum proportion of students

that was included in the survey for substance abuse. WHO recommendation for substance

abuse study is that 10% of the sample frame be recruited which for this population is 574.

Since the minimum calculated sample size is less than the WHO recommendation, therefore

574 was used for this study in line with WHO recommendation. A 20% attrition rate

allowance was made which resulted in an additional 115 persons. Therefore 689 students

were recruited for screening. 68

Training of research assistants

The researcher recruited two research assistants for the study who were registrars in

Paediatrics department. The assistants were trained to administer the study tools in an exam

like manner. They also helped to supervise the participants while they completed their

questionnaires unitarily.

Level of participation

Apart from assistance in administering the questionnaires, the rest of the data

collection was done by the researcher personally.

Pilot Study.

A pilot study was carried out with 50 student from Hope High international

Secondary school (not included in the sampling procedure) to assess the appropriateness of

study tools, perfect the intended methodology and provide a training opportunity for research

assistants before the commencement of the study. Out of the 50 consenting students selected

49

for the pilot study, 40 questionnaires were fully filled giving 20% attrition. Adjustments in

language were then made on the questionnaire before administering same at the subsequent

study.

Sampling Procedure

Selection of schools.

There were 13 approved secondary schools in Abakaliki. Schools were stratified by

gender into male, female, and coeducational schools. Two schools were girls only, two were

boys only, while nine were coeducational. Excluding the school where a pilot study was

carried out reduced the number of mixed schools to eight. Furthermore, the authorities of two

schools declined consent leaving the researcher with six schools to select from. All schools

had their names written on sheets of paper for blinding and subsequently grouped into strata.

The mixed schools were grouped into three strata with two schools in each stratum which

when combined with the boys only and girls only gave a total of five. One school was

subsequently selected from each stratum by ballot method. One male, one female and three

mixed, schools were therefore selected. The schools selected and the respective number of

students in SS2 and SS3 are shown in Appendix VI.

Selection of respondents.

Respondents were selected from each school pro rata, according to their school

population, and the number of class arms. The population of the SS2 and 3 students of the

selected schools were obtained. A ratio of the percentage of the population in each school to

the total population of SS2 and SS3 students was established, and this ratio was used to select

the required number from each school such that the more populous schools had a higher

number recruited for study. Viz;

50

Population at each school X calculated sample size (689)

Total population of students in selected schools (2210)

Subsequently, the respondents were selected from the various classes using the systematic

interval width (I) which was calculated using the fomular,108

I = N

n

Where N is the number of students in the whole arms of a class and

n is the number to be selected from the class. For instance in Nnodo boys secondary school

which had a total of 402 from which 125 were selected, the sample width was 3.3 therefore

every 3rd student was selected from the last one selected from the class according to their

appearance on the class register. The first person was selected randomly and subsequently the

interval width was applied to avoid bias. At the coeducational schools, students were

stratified further into male and female, equal proportions were then selected from both male

and female strata using systematic sampling as previously described. The schools selected

and the respective number of participants selected in each school is represented in Appendix

VI.

Coding of participants

All selected participants were given a code which was known only to the researcher.

The code was written on their Questionnaire. With the code all participants could be

recognized from the class register by the researcher alone.

Selection of subjects and control

Having administered the drug use questionnaire, respondents who abused any

substance were included in the study if they satisfy the inclusion criteria. A respondent was

51

selected as a substance abuser if he/she had an uncontrollable (excessive) use of licit

substances like alcohol, coffee, cigarette and kola nut. This was estimated by the number of

respondents who responded affirmatively to the question ‘have you tried to stop or reduce

your use of substances in the past 12 months and found that you were unable to do so?’.

Secondly any use of an illicit substance like cannabis or cocaine was regarded as abuse as

defined by Odejide.39 However, subjects had to be current users of illicit substances, which is

use within the past 30 days preceding the study, to be selected as a substance abusers.

Controls were selected from the class registers if they were matched with subjects for age,

sex, and socioeconomic class and were in the same arm and class with the subjects in the

academic session that was reviewed. Controls were selected from those who filled the drug

use questionnaire and were found to be non-substance-abusing.

SCHOOLS SELECTED, TOTAL AND SELECTED POPULATION OF SS 2 AND

3 STUDENTS.

School Total Number in SS2 and SS3(Selected)

1. Nnodo boys secondary school…………………………….………..402(125)

2. Urban Model Secondary School, Abakaliki (public, co-educational).623(194)

3. Girls Secondary School, Abakaliki ………………………………….321(100)

4. Holy Ghost College, Abakaliki (private, co-educational)…...............320(100)

5. Presco Secondary School(public, co-educational)…………..............544(170)

Total population in SS2 and SS3 in selected school…………………….2210(689)

Survey Instruments and Parameters to be evaluated.

The study instruments used for the study were:

52

(1) The WHO students drug use questionnaire81 (see Appendix VI) for assessing the prevalence

and factors associated with substance abuse. The first part of the questionnaire, described

basic socio-demographic information like age, sex, religion, year of study at school, parental

education and occupation from which socioeconomic class was determined as proposed by

Olusanya108(see Appendix VII). Section B described the substances abused. Substances that

were studied were alcohol, cigarette, kola nut, coffee, cannabis and cocaine and the popular

local names like ‘igbo’, ‘wee-wee’, ''grass'' were added in the questionnaire for easy

identification by respondents.30 This section also described when and how the respondent was

initiated into substance use.

A participant was selected as a substance abuser if he/she had an uncontrollable

(excessive) use of licit substances like alcohol, coffee, cigarette and kola nut. This was

estimated by the number of respondents who responded affirmatively to the question ‘have

you tried to stop or reduce your use of substances in the past 12 months and found that you

were unable to do so?’. Secondly any use of an illicit substance like cannabis or cocaine was

regarded as abuse as defined by Odejide.39 However, subjects had to be current users of illicit

substances, which is use within the past 30 days preceding the study, to be selected as a

substance abusers. Respondents who did not meet these criteria were considered users not

abusers.

(2) Assessing the seriousness of adolescent drug abuse (ASADA) score53 (see Appendix VIII)

for assessing the severity of substance use. Severe substance use was taken as a total score of

4 and above.

(3) The class attendance register was used to assess school absences in the preceding school

session. High absence was taken as >12 school days absence from the school in a year as

recommended by Weitzman et a,79 while low absence is 1 – 12 school days absence.

53

(4) The Paediatric Symptom Checklist (PSC)- Youth Report Version99 (see Appendix IX) for

assessing psychosocial impairment in substance abusers. A total score of 28 and above was

taken as an indication of significant psychosocial impairment.24

(5) The proforma on school academic report (see Appendix X) adopted from Ogunfowora’s

study109 was used for assessing academic performance of these children. It used information

obtained from the class examination result register. A modification of this tool was made by

substituting Biology for integrated science and Igbo for social studies. This is because this

study was carried out amongst senior secondary students who do not offer social studies and

science as subjects but offer biology and Igbo language since one of biology, chemistry, and

physics and one Nigerian language must be subjects of choice according to WAEC

registration criteria.110

The overall score in percentage in the three terminal examinations of the school

session preceding the study was documented and the average taken. This was used as an

index of general academic performance. The performance was scored as high if ≥75%

whereas 50-74% and <50% were scored as average and low, respectively.87-89 Scores of

<50% were considered as poor academic performance. Scores in 4 subjects, English,

Mathematics, Biology, and Igbo were also compared likewise in accordance with

Ogunfowora’s criteria.

Procedure

The researcher recruited two assistants. Pre-tests of the drug use questionnaire,

ASADA score questionnaire and the PSC- Youth Report Version were done with 50 students

in a co-educational secondary school that was not included in the selected schools. This

helped to identify and modify any ambiguity in the instrument. A familiarization visit was

then paid to each selected school during which the researcher obtained consent from the

54

schools’ authority and obtain a convenient date for the study. The researcher was also

introduced to the parents by school authorities during their parents’ teachers’ association

termly meeting. Parental consent was obtained thereafter and those who were absent had

other subsequent visits scheduled to obtain consent.

On the selected day of study, the researcher was introduced to all students by the

principal or a representative. Selected participants were gathered in a school hall, not in their

classrooms, to fill the questionnaire independently. Explanation on the nature of the

questionnaire, and the need for truthful responses was done. The students were assured of

anonymity and confidentiality to reduce their anxiety regarding victimization and to detect

their real pattern of substance use. Their teachers were not allowed into the hall during the

filling of the questionnaire. The session lasted 60 minutes during which the participants filled

the drug use questionnaire, the ASADA score questionnaire and the PSC questionnaire.

Adequate guidance was given to the respondents by the researcher and/or her assistants

during the questionnaire administration without influencing their responses.

Data collected at this visit was analyzed with the help of a biostatistician to determine

prevalence and pattern of substance abuse. Substance abusing students were then identified

based on the code they were given on the day they filled the substance use questionnaire.

Control subjects were selected subsequently from their class registers systematically.

School absence and academic performances were evaluated for both subjects and

controls. Psychosocial impairment for both subjects and control were assessed by

determining those who had PSC scores of 28 and above. Also, seriousness of drug abuse was

assessed by determining the subjects with ASADA score of 4 and above.

55

Data from these was used to compare the academic performance of substance abusers

and non-abusers and to assess the influence of school absence, severity of substance abuse

and psychosocial impairment on academic performance in subjects and controls.

Data Analysis

Data obtained was analyzed using SPSS Version 20 (IBM SPSS Statistics for

Windows, Version 20.0. Armonk, NY: IBM Corp 2011). Descriptive statistics was used to

find the prevalence of substance abuse. The student’s t-test was used to compare means of

overall scores and scores in key subjects of substance abusers and controls while frequencies

in 2 X 2 tables were compared using the Pearson’s chi-square test or fishers’ exact test as

appropriate. Multiple linear regressions were used to find the associations between

independent variables and the dependent variable, academic performance. All calculations

were based on a significant level of p<0.05.

RESULTS

56

A total of 689 students aged 10-19 years were screened for substance abuse. Sixty-

nine was excluded from the study which consisted of 28 whose responses were inconsistent

and 41 questionnaires that were incompletely filled. Thus 620 (297 males and 323 females)

were finally surveyed giving a response rate of 90.0%. The mean age of the participants was

16.57+1.39 years with a male: female ratio of 1: 1.09. The proportion of respondents aged

10-14 years were 6.9% while 93.1% were aged 15-19 years. SS2 students constituted 51.5%

of respondents while 48.5% were in SS3. Respondents who were from divorced/separated

homes constituted 12.5% of total respondents while 16.1% were orphans. Respondents who

did not abuse any substance were 416 (67.1%) while 204 (32.9%) were abusers of one or

more substances (Table I). Therefore the 204 participants who abused one or more substances

were the subjects while 202 non substance abusers that matched subjects with respect to age,

gender and socioeconomic class served as the control.

Table I: Number of Respondents and Number of Substances Abused.

Number of substances abused N (%)

0 416(67.1)

1 108(17.4)

2 62(10.0)

3 21(3.4)

4 10(1.6)

5 1(0.2)

6 2(0.3)

Total 620(100.0)

Socio-demographic characteristics of substance abusers and controls

57

Table II shows the socio-demographic characteristics of subjects and control. The

mean age for subjects was 17.09+1.33 years while that of controls was 17.02+1.34years

(t=21.402, p=0.623). Subjects were made up of 120 (58.8%) males and 84 (41.2%) females

giving a male: female ratio of 1.4:1. Males were 120(59.4%) while females were 82 (40.6%)

in the control group (χ2=0.634, p=0.541). Socioeconomic stratification showed that 151

(74.5%), 32 (15.5%) and 21 (10.2%) of subjects belonged to the lower, middle and the upper

strata (χ2=1.139, p=0.566). There were no significant differences in age, gender and

socioeconomic class between subjects and controls.

Table II: Socio-demographic characteristics of subjects and controls.

Socio-demographic

variable

Subjects n(%) Control n(%) P

Age range (years)

10-14 9(4.5) 9(4.5) 0.623

15-19 195(95.5) 193(95.5)

Gender

Male 120(58.8) 120(59.4) 0.541

Female 84(41.2) 82(40.6)

Socioeconomic class

Lower 151(74.5) 147(72.7) 0.566

Middle 32(15.5) 40(20.0)

Upper 21(10.0) 15(7.3)

Prevalence of Substance Abuse.

58

Table III shows the types of substances abused by the subjects and prevalence rates.

Alcohol was the most commonly abused substance with a prevalence rate of 29.0% while

cocaine was the least abused with a rate of 2.1%. The prevalence rate for substance abuse

obtained was 32.9% (male= 42.7%, female = 23.1%). All abusers of cannabis, 32(5.2), and

cocaine, 13(2.1), abused alcohol. Abusers of alcohol alone were 31 (5.2%) while 22 (3.5%),

30 (4.8%), and 25 (4.0%) were abusers of cigarette alone, kolanut alone, and coffee alone

respectively. The prevalence of individual and combination substances of abuse are

represented in Table IV.

Table III: Prevalence of Substance Abuse

Substances abused Freq(%)*

Alcohol 180(29.0)

Kolanut 152(24.5)

Coffee 97(15.6)

Cigarette 89(14.4)

Cannabis 32(5.2)

Cocaine 13(2.1)

* Some Subjects abuse more than one substance

Table IV: Prevalence of individual and combination substances of abuse.

59

Substances abused Frequency(%)

Alcohol alone 31(5.2)

Kolanut alone 30(4.8)

Coffee alone 25(4.0)

Cigarrete alone 22(3.5)

Cannabis alone 0(0.0)

Cocaine alone 0(0.0)

Kolanut + Coffee 24(11.8)

Alcohol + Cigarette 21(10.3)

Alcohol + Cannabis 11(5.4)

Alcohol + Cocaine 6(2.9)

Cigarette + Coffee + Kolanut 10(4.9)

Alcohol + Coffee + Kolanut 8(3.9)

Alcohol + Cigarette + Kolanut 3(1.5)

Alcohol + Cigarrete + Cannabis + Kolanut 4(2.0)

Alcohol + Cigarette + Cocaine + Canabis 4(2.0)

Alcohol + Cigarette + Cocaine + Canabis + Kolanut 1(0.5)

Alcohol + Cigarette + Cocaine + Canabis + Kolanut + Coffee 2(1.0)

Factors Influencing Prevalence of Substance Abuse.

Age.

60

Table V shows the prevalence of substance abuse by age group. It demonstrates that

90.8%, 44.6% and 76.9% of 15-19 years old subjects abused alcohol, cigarette and kolanut

respectively. These were statistically significant. There were no significant differences in the

ages of those who abused cannabis, cocaine, and coffee.

Table V: Prevalence of Substance abuse within Age groups.

Age group(years)

Substances

abused

10-14

N=9

15-19

N=195

Fishers exact P

Alcohol n(%) 3(33.3) 177(90.8) 18.201 0.001*

Cannabis n(%) 1(11.1) 31(15.9) 0.961 0.348

Cigarette n(%) 2(22.2) 87(44.6) 10.346 0.002*

Cocaine n(%) 0(0.0) 13(6.7) 1.230 0.623

Coffee n(%) 3(33.3) 94(48.2) 1.670 0.134

Kolanut n(%) 2(22.2) 150(76.9) 2.342 0.243*

N= total number of subjects in that age group

n= number of subjects who abused the various substances within the age group

*=significant

Note some were abusers of more than one substance.

Gender.

The association between abuse of the various substances studied and gender is shown

in Table VI below. More males (99.2%, 46.7%, and 7.5%) were abusers of alcohol, cigarette

61

and cocaine respectively. There were 63.1% female coffee abusers while 36.7% males were

coffee abusers. There was a significant gender difference in abusers of alcohol (p=0.012),

cigarette (p=0.045), cocaine (p=0.042) and coffee (0.031).

Table VI: Prevalence of Substance abuse according to Gender.

Substances

Abused

Male

N=120

Female

N=84

Total

N=204

χ2 p

Alcohol n(%) 119(99.2) 61(72.6) 180(88.2) 27.460 0.012*

Cannabis n(%) 18(15.0) 14(16.7) 32(15.7) 0.598 0.243

Cigarette n(%) 56(46.7) 33(39.3) 89(43.6) 6.789 0.045*

Cocaine n(%) 9(7.5) 4(4.8) 13(6.4) 1.389 0.042*

Coffee n(%) 44(36.7) 53(63.1) 97(47.5) 3.764 0.031*

Kolanut n(%) 87(72.5) 65(77.4) 152(74.5) 2.772 0.312

N= total number of subjects within gender

n=number of subjects who abused the various substances within gender

*=significant

Note some were abusers of more than one substance.

Age at initiation of substance use.

Table VII represents the association between substance abuse and age at first use of

substance. The respondents who abused the various substances had their first use of

62

substances at < 14 years except cocaine that was at 15-19 years and these were statistically

significant.

Table VII: Association between substance abuse and age at first use

Age at first use of substance(years)

Substances

abused

<10

10-14

15-19

χ2

P

Alcohol 26(14.4) 102(95.3) 38(21.1) 63.657 0.000

Cannabis 4(12.5) 25(78.1) 13(40.6) 8.646 0.000

Cigarette 17(19.1) 45(50.6) 28(31.5) 89.492 0.000

Cocaine 0(0.0) 5(38.5) 8(61.5) 7.407 0.000

Coffee 45(46.4) 29(29.9) 15(15.5) 9.351 0.000

Kola nut 72(47.4) 58(38.2) 16(10.5) 16.646 0.000

Socioeconomic class

The lower socioeconomic class had 18.8% cigarette abusers, while the middle and the

upper socioeconomic classes had 8.5% and 8.4% as cigarette abusers (χ2=11.804; p=0.003).

Among kola nut abusers 28.2% belonged to the lower class, 24.6% to the middle class while

15.8% belonged to the upper class (χ2=6.159; p=0.046). There was no significant difference

in the frequencies of abusers of alcohol, cannabis, cocaine and coffee in the various

socioeconomic classes.

Respondents’ year of study.

Concerning their year of study, 29.7% and 20.0% of SS3 respondents abused kola nut

and coffee respectively as against 21.4% and 12.7% who abused kola nut and coffee in SSII

63

(χ2=5.332; p=0.021; for kolanut and χ2=5.918; p=0.015; for coffee). Cigarette, alcohol,

cannabis, and cocaine showed no significant difference in the frequency of abusers in the two

years of study (p=0.532, 0.246, 0.346, and 0.498 respectively).

Family structure

Cannabis and cigarette abusers were more amongst those who were orphaned

(p=0.042 and 0.027 respectively). Cigarette, alcohol, cannabis and kola nut showed a

64

significantly higher frequency amongst those who belonged to divorced families (p=0.002,

0.046, 0.006 and 0.024 respectively). The findings are shown in Table VIII

Table VIII: Family structure of total respondents and its association with abuse of

various substances

Substances abused Divorced/separated?

Yes (N=78) No (N=542)

Fishers

exact

p-value

Alcohol 60(76.9) 120(22.1) 3.423 0.046*

Cannabis 25(32.1) 7(1.3) 9.342 0.006*

Cigarette 51(65.4) 38(7.0) 7.232 0.002*

Cocaine 2(2.6) 11(2.0) 1.283 0.521

Coffee 14(17.9) 83(15.3) 1.670 0.142

Kolanut 51(65.4) 101(18.6) 6.345 0.024*

Orphan?

Yes (N=100) No (N=520)

Alcohol 36(36.0) 144(27.7) 2.421 0.323

Cannabis 18(18.0) 14(2.7) 6.236 0.042*

Cigarette 49(49) 40(7.7) 10.748 0.027*

Cocaine 3(3) 10(1.9) 3.271 0.243

Coffee 20(20) 77(14.8) 2.346 0.421

Kolanut 31(31) 121(23.3) 1.634 0.224

N= total number of respondents in the group *=significant

Academic Performance

Table IX shows the overall scores of substance abusers and that of controls. One

hundred and thirty seven (67.3%) subjects had low overall scores, compared to 72 (35.8%)

65

controls. The difference in academic performance of subjects and controls was statistically

significant (χ2 = 22.021; p=0.000).

Table IX: Overall academic score of subjects and control

Overall score Subjects n(%) Control n(%) Total n(%)

High (>75) 4(1.8) 11(5.5) 15(3.7)

Average (50-74) 63(30.9) 119(58.7) 182(44.7)

Low(<50) 137(67.3) 72(35.8) 209(51.6)

χ2 = 22.021; p=0.000

The mean scores of subjects and controls in specific subjects and in the overall score

are shown in table X. The mean score of controls was significantly higher than those of the

subjects in the overall score and in all four key subjects. There were significant p-values in all

cases.

66

Table X: Mean scores of subjects and controls in selected key class subjects and their

overall score.

Scores of abusers Scores of control

Class subject Mean SD Mean SD t pvalue

Biology 42.32 15.73 54.12 15.98 5.512 0.000

English 41.25 17.98 50.01 16.98 3.714 0.000

Igbo 39.63 16.99 52.92 14.98 6.143 0.000

Mathematics 35.74 13.96 43.76 15.16 4.071 0.000

Overall 43.44 14.54 54.21 13.47 5.692 0.000

Factors Associated with Academic Performance of Subjects.

School absence

67

The mean number of days the subjects were absent from school in the 2012/2013

session was 14.68+4.79 days while that for the control was 9.50+3.84 days and this

difference was statistically significant (t = -8.821; p=0.000).

The relationship between school absenteeism and overall score of subjects and

controls is shown in table XI. There was a significant relationship between the rate of school

absenteeism and overall score for substance abusers and controls, the level of significance is

as shown in table XI.

Table XI: Association between school absence and overall academic score of subjects

and controls.

School absence

Overall score Low High Total

Low Abusers n(%) 17(12.2) 120(87.8) 137

Controls n(%) 40(56.4) 32(43.6) 72

Average Abusers n(%) 36(56.4) 27(35.3) 63

Controls n(%) 113(95.3) 6(4.7) 119

High Abusers n(%) 2(50.0) 2(50.0) 4

Controls n(%) 11(100.0) 0(0.0) 11

Total Abusers n(%) 59(29.1) 145(70.9) 204

Controls n(%) 165(81.7) 37(18.3) 202

Statistics for subjects: fishers exact 30.85; p=0.000

Statistics for controls: fishers exact 23.88; p=0.000

Psychosocial Impairment.

Generally, 117 (28.8%) of study population had psychosocial impairment while 289

(71.2%) were normal. Students with normal paediatrics symptoms checklist score were found

68

to perform significantly better academically ( χ2=8.75 ; p=0.024). The mean PSC score for

substance abusers was 21.96+10.77 while that for controls was 16.07+8.69. The difference

was statistically significant (t=-6.74; p=0.000). Eighty-nine subjects (43.7%) and 28 controls

(13.9%) had abnormal PSC scores. The association between PSC score and the overall

academic score of substance abusers, as shown in table XII, was statistically significant.

Table XII: Association between psychosocial dysfunction and overall academic score of

substance abusers and controls

PSC Score

Overall score Normal Abnormal Total

Low Abusers n(%) 70(51.4) 67(48.6) 137

Controls n(%) 61(84.7) 11(15.4) 72

Average Abusers n(%) 45(71.0) 18(29.0) 63

Controls n(%) 104(87.3) 15(12.7) 119

High Abusers n(%) 0(0.0) 4(100.0) 4

Controls n(%) 9(83.3) 2(16.7) 11

Total Abusers n(%) 115(56.3) 89(43.7) 204

Controls n(%) 174(86.1) 28(13.9) 202

Statistics for subjects: Fishers exact 5.54;p = 0.046

Statistics for controls: Fishers exact 0.55;p = 0.821

Type of substance abused

69

Table XIII shows the academic performance of subjects using different substances of abuse.

The proportion of low scorers who were alcohol abusers was 91.2% while 84.1% of average

scorers were alcohol abusers. Cannabis and cocaine abusers constituted greater proportion

among low scorers than among average or high scorers. Kolanut and coffee had comparable

proportion of their abusers among low and average scorers.

Table XIII: Academic performance of subjects using different substances of abuse.

Overall score

Substances abused Low (N=137) Average (N=63) High (N=4)

Alcohol 125(91.2) 53(84.1) 2(50.0)

Cannabis 30(21.9) 2(3.2) 0(0.0)

Cigarette 62(45.3) 27(42.9) 1(25.0)

Cocaine 13(9.5) 0(0.0) 0(0.0)

Coffee 65(47.4) 32(50.8) 4(100.0)

Kolanut 99(72.3) 53(84.1) 4(100.0)

*Percentages in parenthesis and within the scores.

Gender

The overall class score was not significantly influenced by gender in both substance

abusers and controls. Eighty seven (63.5%) and 48 (66.7%) of low scorers, for subjects and

control respectively, were males. Whereas, 4 (100.0%) and 9 (83.3%) of high scores were

males (subjects and control respectively).

Socioeconomic status

70

There was no significant association between the overall scores of both subjects and

controls and their socioeconomic status. The proportion of low scorers among the lower

socioeconomic class for subjects and control were 83.8% and 84.6% respectively, those of

the middle socioeconomic class were 9.5% (subjects) and 12.8% (control) while the

proportion of low scorers among the upper socioeconomic class were 6.8% (subjects) and

2.6% (control).

Severity of substance use using ASADA score and academic performance.

Fifty nine (29.1%) of subjects had ASADA scores >4. Fourty one (69.5%) of subjects

with severe substance abuse had low scores while 97(66.8%) of subjects who had ASADA

score less than 3 had low academic scores. There was no significant association between the

severity of substance use, measured by the ASADA score, and the overall score in 2012/2013

session ( χ2=4.081; p=0.092).

71

Number of substances used and academic performance.

Table XIV shows the association between the number of substances used and the

overall score of participants. There was a progressive increase in the proportion of poor

performers as the number of substances used increased.

Table XIV: Association between the number of substances abused and overall academic

score of subjects.

Overall score

Number of substances

used

Low Middle High Total

0 72(35.8) 119(58.7) 11(5.5) 202

1 48(44.4) 56(51.9) 4(3.7) 108

2 55(88.7) 7(11.3) 0(0.0) 62

3 21(100.0) 0(0.0) 0(0.0) 21

4 10(100.0) 0(0.0) 0(0.0) 10

5 1(100.0) 0(0.0) 0(0.0) 1

6 2(100.0) 0(0.0) 0(0.0) 2

Total 209(51.6) 182(44.7) 15(3.7) 406

Fishers exact 6.84; p=0.026

72

MULTIPLE LINEAR REGRESSION ANALYSIS OF THE FACTORS ASSOCIATED

WITH ACADEMIC PERFORMANCE.

Table XV shows the result of the multiple regression analysis of the factors associated

with academic performance amongst substance abusers. Three factors, age at initiation of

substance use, number of substances used and frequency of school absenteeism, were found

to have significant independent effects on academic performance of substance abusers.

Among the control, school absences had a significant independent effect on the overall score.

Table XV: Multiple regression analysis of factors associated with academic

performance of substance abusers and controls.

VARIABLE Coefficient R2 change 95% Interval Partial P

SUBSTANCE ABUSERS

Age of initiation -0.253 -0.361 -4.54 to -0.77 -0.289 0.006*

Psychosocial dysfunction -0.029 -0.188 -0.33 to 0.25 -0.029 0.786

Degree of school absence -0.504 -0.601 -2.049 to -

1.01

-0.533 0.000*

No of substances -0.323 -0.432 -3.23 to -0.86 -0.321 0.003*

CONTROL

PSC score -0.052 -0.025 -0.39 to 0.23 -0.054 0.602

Degree of school absence -0.490 -1.075 -2.34 to -1.08 -0.49 0.000*

*=significant

73

DISCUSSION

The prevalence rate of substance abuse obtained from this study is 32.9%. A previous

study30 done five years ago in this environment obtained a prevalence of 27.1%. In keeping

with previous studies in south eastern Nigeria,30,33,47,50 alcohol was the most commonly

abused substance. This finding, may be attributable to the availability of various brands of

alcoholic beverages in the study area. However, reports from western32,51 and northern56

Nigeria showed that cigarette was the most commonly abused substance. The difference in

finding may be due to cultural differences between the South Eastern, Northern and Western

Nigeria.

It is pertinent to note that 47% of subjects, abused more than one substance.

Substance abuse disorders therefore may be causing significant morbidity amongst our

adolescent population. As a result, more efforts need to be exerted to bring the use and abuse

of substances to the barest minimum. Substance abuse is more common among male

adolescents. This is consistent with observed trend in Nigeria2,4,15,16,30,48,50 and globally.7,13,14

The reason may be attributable to the more adventurous nature of males especially during

adolescence.30

Cigarette and kola nut abuse were more amongst adolescents of lower socioeconomic

class. The abuse of other substances did not show any significant association with

socioeconomic class. This observation contrasts with the findings of Abiodun et al31 in Ilorin,

and Odejide et al49 in Ibadan, Western Nigeria. They reported that adolescents from upper

socioeconomic class abused substances more than those from other socioeconomic classes.

Abiodun et al31 as well as Odejide et al49 attributed this to increased availability of these

substances to this class of adolescents based on costs. The reason for the preponderance of

cigarettes and kola nut abuse among the adolescents of lower socioeconomic class in

74

Abakaliki may be economic. Kola nuts and cigarettes are cheap and readily available. The

practice of giving kolanut as a sign of acceptance of a visitor among the Igbos could also

account for a high preponderance of kalanut abuse in Abakaliki. Another possible

contributing factor could be parenting style. Adolescents with permissive parents; and those

whose parents abuse substance are more likely to abuse substances.36 Parents of the lower

socioeconomic classes have been reported to have less supervision of their adolescent

students. This may make them vulnerable to negative peer influences at school.36

Age of the respondent was found to be significantly associated with the abuse of

cigarettes and alcohol. Most of the abusers were older and in the late adolescence. Ngesu et

al8 in Kenya and Adelakan and Ndom16 in Nigeria made similar observations. Older students

have stayed longer in school, and therefore have been exposed to stronger and sustained peer

influences. Adolescents found to be substance abusers were observed to have had their first

use of these substances in early adolescence. This is because the use of substance has strong

appeal for those beginning their independence as they search for identity.4,41,48 Early

adolescence is characterized by innate curiosity and thirst for new experiences. They are

therefore susceptible to experimentation with drugs at this age.36 Furthermore, because

adolescents at this stage lack the knowledge of consequences of actions and self-will, they

may progress from experimentation with substances to addiction in later years.36,49

Adolescents who were orphaned were more likely to abuse cannabis and cigarettes

while the abuse of cigarettes, alcohol, cannabis and kola nuts were more in adolescents from

divorced homes. Similar findings of high prevalence of substance use and or abuse among

students from dysfunctional homes have been reported severally in the literature. 30,43,52 This

may be due to lack of discipline, poor supervision and poor personality development which is

often associated with single parenting.4,15,31

75

The mean overall academic score of substance abusing adolescents, was significantly

lower than that of the control. The poor academic achievement of these students may be due

to the direct effect of these substances on cognition or the associated increased school

absence. School absence was more common among substance abusing students. In this

report, high school absence is associated with poor school performance. This finding supports

the assertion of Cox et al26 that heavy drinking of alcohol, frequent smoking of cigarette and

cannabis use resulted in low academic performance as measured by school reports of

performances in mathematics and Spanish language. Ingles et al69 corroborated this, having

observed poor academic performance in adolescents who abused alcohol or smoked daily.

Ingles et al69 attributed poor academic performance to lack of interest on school

achievements or interference with study tasks induced by the use of substances. In addition,

the “hang-over” effect of alcohol use for instance may result in poor concentration and sleep

during lessons and examinations.

It is worthy to note that despite the poorer performance of subjects when compared to

that of control, students in both groups performed generally poor academically. This finding

is consequent upon the observation of the high prevalence of low overall score of 67.3% and

35.8% in substance abusers and controls respectively. High scorers were 1.8% and 5.5% in

subjects and controls respectively. There are obviously other factors contributing to this poor

academic performance in the general population of students in Abakaliki. The reason for this

was not explored in this study.

However, academic failure amongst controls in this study (35.8%) is remarkably

higher than previous studies by Ibekwe et al90 and Ogunfowora et al89 who reported

prevalence rates of 16% and 7.7% respectively in their controls. Ogunfowora‘s participants

were mainly from the upper socioeconomic class and Ibekwe’s study had equal

representation of all socioeconomic classes. In present study, more of the participants were

76

from the lower socioeconomic class. Previous report have highlighted the relationship

between socioeconomic class and academic performance.75 This may partly explain the

higher prevalence of academic underachievement in controls demonstrated in the my study.

Another contributing factor may be the high proportion(70.9% for subjects and 18.3% for

controls) of adolescent with high school absence rate in in my study population. School

absenteeism is known to affect academic performance especially in substance abusing

students.75-77

Substance abusing students performed worse than controls in all the key subjects

studied. Cox et al26 who studied public high school students observed lower scores in

mathematics and Spanish language amongst heavy substance users. However my study shows

poor performance in mathematics amongst both substance abusers and controls. The reason

for this is not clear. Lynsky21 had suggested that the reason for poor academic performance in

substance abusers is that substance use itself may have a direct effect on cognitive

development which in turn results in academic underachievement and disruption of progress.

Similarly, Engberg and Moral,22 King et al,23 and Pope and Yurelun-Todd24 reported that

heavy substance use can result in problems in working memory and attention due to changes

in brain activity induced by the use of substances which may culminate into school problems

and eventual dropout. The same studies,21-24 emphasized that the degree of substance use, as

well as the use of multiple substances rather than the type of substances used was associated

with poor academic performance.

School absenteeism was more amongst substance abusers than control. Similar

findings were made by Godley70 who reported more risky behaviours such as truancy among

substance abusers. This finding was corroborated by Okike30 who performed a similar study

on substance abuse in adolescents in Abakaliki five years ago. He observed that school

absenteeism was a consequence of the various substances he studied. It has been posited that

77

these substances produce “hang over” effects on the abuser thereby making school attendance

difficult. Other reason given is that these students prefer to “hang out” with peers rather than

participate in school activities. School attendance is a critical factor in school success of

students. Students who absent themselves from school lose out on the preparatory classes and

tend to perform worse than their peers.79 This is confirmed by the finding of academic

underachievement among children with high school absence rate in the present study.

Substance abusers in this study had higher rate of psychosocial dysfunction, 43.7%

compared to 13.9% among controls. The fact that psychosocial dysfunctions are common

among substance abusers has been previously reported.65,66,73 However, the prevalence of

psychosocial dysfunction,43.7%, obtained in this study is higher than 24.1% reported in a

previous study using similar rating scale in 2010.73 The observed difference may be due to

the varying definitions used for subjects. While this study recruited all substance abusers as

subjects, the previous study73 recruited only current users of substances. Langas et al72

reported that 46% of their substance users had personality disorders which were more or less

a function of the age at which substance abusers initiated substance use. Substance abusing

students with psychosocial impairment performed significantly worse than those without

psychosocial impairment. This corroborates the finding of Gruber et al78 that there is

increased prevalence of inattention in heavy substance abusers. Gruber et al78 reported that

the impaired critical skills are related to attention, memory and learning problems amongst

heavy users of cannabis. Poor performance may also be due to loss of concentration during

lessons and class assessments from psychosocial dysfunctions as postulated by Gruber et al.78

Although this study has shown a significant association between gender and the abuse

of some substances with more males as substance abusers, there was however no significant

association between the overall scores of substance abusers and control with respect to

gender. The reason for this is unclear. Although it suggests that there may be other factors

78

affecting academic performance such as the individual’s natural ability, conscientious study

and school attendance. Similarly socioeconomic class was noted not to be significantly

associated with academic performance a trend that has been noted by other authors.89-91 The

performance of all the students was generally poor in spite of their social class. This shows

that participants, both abusers and control, may be exposed to similar factors which could

account for their general poor performance.

The type of substance abused rather than the severity of substance used was noted to

be associated with the academic performance of these students. Students that abuse cigarettes,

alcohol, and cannabis and cocaine performed poorly in school. Abusers of kolanut and coffee

had similar proportion of subjects within the low and average score group. This may be due

to the central acting nature of alcohol, cigarrete , cannabis, and cocaine and their tendency to

cause addiction. It could also be due to inattention, and impairment in memory and thought

caused by these substances as reported by Gruber et al.78 Unlike these substances, kola nut

and coffee has been shown to have less central toxicities .30,73

The number of substances used has been shown to be significantly associated to

academic performance in this study. There was a significant increase in proportion of

participants with a low overall score as the number of substances used increased. This may be

due to the additive pharmacologic toxicities of these substances. Igwe and Ojinnaka73 had

earlier noted multiple substance use as a risk factor for psychiatric morbidity in students that

abuse substances. The resultant psychosocial impairment of multiple substance use may

result in poor concentration and poor thought which could adversely affect school

performance.

Multiple linear regressions showed that school absences, age at initiation of substance

use and number of substances used had significant independent effects on academic

79

performance of substance abusers. This finding agrees with the known relationship between

school absenteeism and academic performance79 as well as the effect of multiple substance

use on mental health of substance abuser which in turn can affect their school

performance.73,78 However the finding of significant independent effect of school

absenteeism on academic performance among control shows that the poor academic

performance of substance abusers may largely be due to school absenteeism rather than

substances related factors. Furthermore, the age of initiation of substance use and the use of

multiple substances rather than the type of substance abused are what preclude good

academic performance in substance abusers.

80

CONCLUSION

The following conclusions can be drawn from the results of this study:

1. Substance abuse is high among secondary school students in Abakaliki and alcohol is

the most commonly abused substance

2. The academic performance of substance abusers is worse than that of students who do

not abuse substances.

3. High school absence, age at initiation of substance use and abuse of multiple

substances are the most important determinants of academic performance of substance

abusers in secondary schools in Abakaliki.

4. School absenteeism is the underlying determinant of academic performance of all

secondary school students whether substance abusing or non-substance abusing in

Abakaliki.

81

RECOMMENDATIONS

Based on the findings of this study, the following recommendations are made:

1. Awareness campaign on the finding of significant prevalence of substance abuse and

its consequences should be made to the general public and inculcated in the

curriculum of secondary school students.

2. School absenteeism should be considered in poor performing students in schools.

82

LIMITATIONS

The direct effect of substance abuse on cognition of the individual could not be ascertained

especially using a cross-sectional means. However a longitudinal study carried out to observe

the substance abuser over a period of time would require enormous resources and participants

may be lost to follow up after they leave the secondary school.

LINES OF FUTURE STUDY

83

Substance abusers in this study had a higher rate of psychosocial impairment than was

previously reported. A study, to determine the factors responsible for this in Abakaliki should

be conducted

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106. Ebonyi State ministry of education, Statistics and Planning Unit. 2012 school

enrolment: 12-24.

107. Araoye MO. Research methodology with statistics for health and social sciences. Ilorin:

Nathadex Publishers. 2003; 115-29.

108. Olusanya O, Okpere EE, Ezimokhai M. The importance of social class in voluntary

fertility control in a developing country. West Afr J Med. 1985; 4: 252-55.

109. Ogunfowora OB. A comparative study of school absence and academic performance of

children with sickle cell anemia and healthy controls. West African Postgraduate

Medical College Dissertation 1994.

110. The West African Examinations Council. Regulations for the West African Senior

School Certificate Examination (WASSCE). Pg 13.

96

registration.waecdirect.org/pdf/Syllabus/INTRODUCTION.pdf assessed 1st

September 2012.

APPENDIX Ia. LETTER OF ETHICAL APPROVAL FROM RESEARCH AND

ETHICS COMMITEE FEDERAL TEACHING HOSPITAL ABAKALIKI (FETHA)

97

APPENDIX Ib. LETTER OF EXTENSION OF DATE OF ETHICAL APPROVAL

98

99

APPENDIX II. LETTER OF INTRODUCTION FROM MINISTRY OF EDUCATION

EBONYI.

100

APPENDIX III: CONSENT LETTER (STUDENTS).

Subjects Identification Number…………………………………

TITTLE OF STUDY: ACADEMIC PERFORMANCE OFSUBSTANCE ABUSING

SCONDARY SCHOOL STUDENTS IN ABAKALIKI.

Dear respondent,

This study is aimed at describing the academic performance of substance abusing

students. You will be asked to fill 3 questionnaires which will take a total of 60 minutes to

do. Thereafter your class attendance and averages in the terms of last academic sessions will

be obtained.

I seek your co-operation to participate in this study and promise that your

confidentiality will be maintained. You will not be victimized for not participating, you are

not exposed to any risks and you have the right to withdraw from the study at any time you

deem it necessary. In addition, your name will not be mentioned in any publication emanating

from this study. You may contact the chairman, Research and Ethics Committee Federal

Teaching Hospital Abakaliki if there is any need to do so.

Thank you.

Dr Onyinye Anyanwu

Principal Investigator.

08033230292.onyinyeanyanwu@yahoo.com.

101

I …………………………………………………….having read this consent letter am willing

to participate in the study on my own freewill without inducement or coercion.

I hereby affirm my willingness to participate in this study.

…………………………… ………………………………..

Name of participant Name of researcher

…………………………. ………………………………

Signature/date of participant Signature/date of researcher

102

APPENDIX IV: CONSENT LETTER (PARENTS/GUARDIAN).

Subjects Identification Number…………………………………

TITTLE OF STUDY: ACADEMIC PERFORMANCE OF SUBSTANCE ABUSING

SCONDARY SCHOOL STUDENTS IN ABAKALIKI.

Dear Sir/Madam,

This study is aimed at assessing the pattern of substance abuse and its influence on

academic performance. Your child will be asked to fill 3 questionnaires which will take a

total of 60 minutes to do. Thereafter his/her class attendance and averages in the terms of the

last academic session will be obtained.

I seek your consent to allow him/her participate in this study and promise that

confidentiality will be maintained. He/she will not be victimized for not participating, is not

exposed to any risks by participating and you have the right to withdraw him/her from the

study at any time you deem it necessary. In addition, his/her name will not be mentioned in

any publication emanating from this study. You may contact, the chairman, Research and

Ethics Committee Federal Teaching Hospital Abakaliki if there is any need to do so.

Thank you.

Dr Onyinye Anyanwu

Principal Investigator.

08033230292.onyinyeanyanwu@yahoo.com.

103

I …………………………………………………………………….having read this consent

letter am willing to allow my child/ward …………………………………………………….

participate in the study on my own freewill without inducement or coercion.

I hereby affirm my willingness to allow my child/ward participate in this study.

…………………………… ………………………………..

Name of parent/guardian Name of researcher

…………………………. ………………………………

Signature/date of parent/guardian Signature/date of researcher

104

APPENDIX V: CONSENT LETTER (PRINCIPAL)

Department of Pediatrics

Federal Teaching Hospital Abakaliki

Sir,

I wish to inform you of my intent to carry out a research on the title “Academic

performance of substance abusing secondary school students in Abakaliki metropolis”. It will

entail filling three questionnaires and assessment of students’ class performance and

attendance. Selected students will be from SS2 and 3. This research will pose no negative

effect to your administration nor your students. I therefore solicit your consent and support to

carry out this exercise in your school. Attached herewith is a letter of introduction from the

Ebonyi State Secondary Education Board.

Thank you.

Dr Anyanwu Onyinye

Principal Researcher.

onyinyeanyanwu@yahoo.com(08033230292)

Consent Given:

Name of Principal…………………………………………………………………

Signature ……………………………………………………………………………

Date …………………………………………………………………………………..

105

APPENDIX VI: WHO STUDENT’S DRUG USE QUESTIONNAIRE.

School…………………………………………….…………………….

Code………………....

1. Gender 1 female 2 male

2. How old are you? Years.

3. a)What is your religion? 0 none at all 1christianity 2Protestant 3Catholic

4Pentecostal 5 Islam 6 traditional African religion

(b) how often do you participate in your religious activities? (eg attending church, mosque,

etc)? 0 rarely or never 1 sometimes 2 oftentimes or regularly .

4.What is your state of origin? [ ] state

5. What is your year of study? 1 SS2 2 SS3

6 How much money (pocket money) do you obtain (from all sources) for your spending each

month? =N= [ ]

7 How much education did your father (or male guardian) receive?(mark the highest level

attained). 0 no formal education 1 some primary school 2 completed primary school

3 some secondary school/secondary modern school 4 completed secondary

school/teacher training school 5 some college(polytechnics college of education) 6

completed college 7 some university 8 completed university 9 don’t know .

8 How much education did your mother (or female guardian) receive?(mark the highest level

attained). 0 no formal education 1 some primary school 2 completed primary school

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3 some secondary school/secondary modern school 4 completed secondary

school/teacher training school 5 some college(polytechnics college of education) 6

completed college 7 some university 8 completed university 9 don’t know .

9 Is your father alive 1.yes 2.No

10 If your answer to question 9 is “NO” how old were you at the time of his death? 1 I was

less than 10 years old 2 I was more than 10 years old 3 I don’t know how old I was

at his death .

11 Is your mother alive? 1.yes 2. No .

12 If your answer to question 11 is “NO” how old were you at the time of her death? 1 I was

less than 10 years old 2 I was more than 10 years old 3 I don’t know how old I was

at her death .

13 a.Are your parents still married to each other? 1.yes 2. No .

b. Who do you live with? ……………………………………… (please write the relationship)

14 (a) if your answer to question 13 is “NO” how old were you at the time of their separation

or divorce? 1 I was less than 10 years old 2 I was more than 10 years 3 I don’t know

how old I was at the time of their separation/divorce .

15 What is your father’s occupation? (Specify) ………………………………………………

16 What is your mother’s highest educational level? (Specify)………………………………

107

17 Does your father smoke cigarette?1 Yes 2 No 3 Not applicable (he is dead) 4

Don’t know .

18 Does your mother smoke cigarette? 1 Yes 2 No 3 Not applicable (he is dead)

4 Don’t know .

19 (a) Have you ever smoked, chewed, or sniffed any tobacco product (such as cigarette,

cigars , pipe tobacco, chewing tobacco)? 1 yes 2 no .

(b) Have you ever smoked, chewed, or sniffed a tobacco product in the past 12 months? 1 yes

2 no .

(c) Have you ever smoked, chewed, or sniffed a tobacco product in past 30 days?1 no 2

yes, 1-5 days out of 30 3 yes, 6- 19 days out of 30 4 yes, 20 or more days out of 30

.

(d) How old were you when you first smoked, chewed, or sniffed a tobacco product? 0. have

never smoked, chewed or sniffed a tobacco product 1. 10 years old or less 2. 11-14

years old 3. 15-19 years old

(e) What was your level of education when you first smoked, chewed or sniffed tobacco

product? 0 have never smoked, chewed or sniffed tobacco product 1 primary school

level 2 secondary school level 3 others (specify)…………………………………….

(f) Have you tried to stop or reduce your use of tobacco product during the last 12months and

found you were unable to do so? 0 not applicable (I don’t take any tobacco product) 1 I

108

have successfully stopped/reduced 2 I have not tried to stop or reduce it 3 I have

tried but was unable to stop or reduce It .

(g) If your answer to 19(f) is “2” why have you not tried to stop or reduce your use of tobacco

products? .........................................………………………...………………………………….

(h)How many sticks of cigarette do you smoke in a day? 1. 1 2. 2 -5 3. 6 – 10

4. More than 10 .

(i) Who initiated you into smoking? 1.Father 2.Mother 3.Friends 4.Nobody

5.Through advertisement 6.Others (specify)

………………………………………………

20 (a) Have you ever drunk any alcoholic beverage including beer, wine, “hot drink”,

“ogogoro”, and palm wine? 1 yes 2 no .

(b) Have you drunk any alcoholic beverage in the past 12 months? 1 yes 2 no .

(c)Does your father drink any alcoholic beverage?1 yes 2 no .

(d)Does your mother drink any alcoholic beverage? 1 yes 2 no .

(e) Have you drunk any alcoholic beverage during the past 30 days? 1 no 2 yes, 1-5 days

out of 30 3 yes, 6- 19 days out of 30 4 yes, 20 or more days out of 30

(f) Have you drunk 5 or more alcoholic drinks at one sitting in 1 or more days during the past

30days? 1 yes 2 no .

109

(g) How old were you when you first had a drink of an alcoholic beverage more than just a

sip? 0. have never drunk alcoholic beverage 1.10 years old or less 2.11-14 years old

3.15-19 years old .

(h) What was your level of education when you first had a drink of an alcoholic beverage

more than just a sip? 0 have never drunk alcoholic beverages 1.primary school level

2 secondary school level 3.others (specify) ……………………………………………….

(i) Have you tried to stop or reduce your use of alcoholic beverage during the last 12months

and found you were unable to do so? 0 not applicable (I don’t take any alcoholic beverage)

1 I have successfully stopped/reduced 2 I have not tried to stop or reduce it 3 I

have tried but was unable to stop or reduce it.

(j) if your answer to 20(i) is “2” why have you not tried to stop or reduce your use of

alcohol?..............................................................................................………………………….

(k)How much alcohol do you take at a sitting?1. Half beer bottle 2. 1 bottle 3. 2 – 4

bottles 4. More than 5 bottles .

(l) Who initiated you into drinking alcohol? 1. Father 2.Mother 3.Friends

4.Nobody 5.Through advertisement 6.Others

(specify)……………………………….

21 (a) Have you ever taken any cannabis (Indian hemp, marijuana, hashish, ganga, igbo etc)?

1 yes 2 no .

(b) Does your father take cannabis? 1 yes 2 no .

110

(c) Does your mother take cannabis? 1 yes 2 no .

(d) Have you taken any cannabis during the past 12 months? 1 yes 2 no .

(e) Have you taken any cannabis during the past 30 days? 1 no 2.yes, 1-5 days out of 30

3 yes, 6- 19 days out of 30 4 yes, 20 or more days out of 30 .

(f) How old were you when you first took cannabis? 0. have never taken cannabis 1. 10

years old or less 2. 11-14 years old 3. 15-19 years old .

(g) What was your level of education when you first took cannabis? 0 have never taken

cannabis 1 primary school level 2 secondary school level 3 others (specify)

……………………………………………………….

(h) Have you tried to stop or reduce your use of cannabis during the last 12months and found

you were unable to do so? 0 not applicable (I don’t take cannabis) 1 I have successfully

stopped/reduced 2 I have not tried to stop or reduce It 3 I have tried but was unable

to stop or reduce it .

(i) if your answer to 21(h) is “2” why have you not tried to stop or reduce your use of

cannabis?..........................................……………………………………………………………

(j) Who initiated you into taking cannabis? 1.Father 2.Mother 3.Friends 4.

Nobody 5.Through advertisement 6.Others (specify) ……………………………….

22 (a) Have you ever taken any cocaine? 1 yes 2 no .

(b)Does your father take cocaine? 1 yes 2 no .

111

(c)Does your mother take cocaine? 1 yes 2 no .

(d) Have you taken cocaine during the past 12 months? 1 yes 2 no .

(e) Have you taken any cocaine during the past 30 days?1 no 2 yes, 1-5 days out of 30

3 yes, 6- 19 days out of 30 4 yes, 20 or more days out of 30 .

(f) How old were you when you first took cocaine? 0. have never taken cocaine 1. 10

years old or less 2. 11-14 years old 3. 15-19 years old .

(g) What was your level of education when you first took cocaine? 0 have never taken

cocaine 1 primary school level 2 secondary school level 3 others (specify)

………………………………………………………

(h) Have you tried to stop or reduce your use of cocaine during the last 12months and found

you were unable to do so? 0 not applicable (I don’t take cocaine) 1 I have successfully

stopped/reduced 2 I have not tried to stop or reduce it 3 I have tried but was unable

to stop or reduce it .

(i) if your answer to 22(h) is “2” why have you not tried to stop or reduce your use of

cocaine?................................................…………………………………………………………

(j)if you have ever taken any cocaine, write the route through which you took it(eg sniffing,

injections):....................................................................…………………………………………

(k) Who initiated you into taking cocaine? 1.Father 2.Mother 3.Friends

4.Nobody 5. Through advertisement 6.Others (specify)

…………………….……….

112

23 (a) Have you ever taken kola nut before? 1 yes 2 no .

(b) Does your father take kola nut? 1 yes 2 no .

(c) Does your mother take kola nut? 1 yes 2 no .

(d) Have you taken kola nut in the past 12 months? 1 yes 2 no .

(e)Have you taken any kola nut in the past 30 days? 1.no 2.Yes 1-5 days out of 30

3. Yes 6-19 days out of 30 4.yes, 20 or more days out of 30

(f)How old were you when you first took kola nut? 1 I have never taken kola nut before

2. 10 years old or less 3. 11-14 years old 4. 15-19 years old

(g) What was your level of education when you first took kola nut? 0.have never taken kola

nut before 1. Primary school level 2. Secondary school level 3 others (specify)

…………………………………………………………

(h) Have you tried to stop or reduce your use of kola nut during the last 12 months and found

that you were unable to do so? 0. Not applicable (I don’t take kola nut) 1. I have

successfully stopped/reduced it 2. I have not tried to stop or reduce it 3. I have tried

but was unable to stop or reduce it .

(i) if your answer to 23(h) is “2” why have you not tried stopping or reducing your use of

kola nut …………………………………..……………………………………………………

(k) Who initiated you into taking kola nut? 1. Father 2. Mother 3. Friends

4.Nobody 5.Through advertisements 6.Others (specify) ……………………………

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24 (a) Have you ever taken coffee before? 1 yes 2 no .

(b) Does your father take coffee? 1 yes 2 no .

(c) Does your mother take coffee? 1 yes 2 no .

(d) Have you taken coffee in the past 12 months? 1 yes 2 no .

(e) Have you taken any coffee in the past 30 days? 1.no 2. Yes 1-5 days out of 30

3. Yes 6-19 days out of 30 4.yes, 20 or more days out of 30 .

(f) How old were you when you first took coffee? 1 I have never taken coffee before

2.10 years old or less 3. 11-14 years old 4. 15-19 years old

(g) What was your level of education when you first took coffee? 0. have never taken coffee

before 1. Primary school level 2. Secondary school level 3 others (specify)

…………………………………………………………

(h) Have you tried to stop or reduce your use of coffee during the last 12 months and found

that you were unable to do so? 0. Not applicable (I don’t take coffee) 1. I have

successfully stopped/reduced it 2. I have not tried to stop or reduce it 3. I have tried

but was unable to stop or reduce it.

(i) if your answer to 24(h) is “2” why have you not tried stopping or reducing your use of

coffee …………………………………………………………………………………………

114

(j) Who initiated you into taking coffee? 1. Father 2. Mother 3.Friends

4.Nobody 5.Through advertisements 6. Others (specify)

….…………………………

25 Are there any other drug not mentioned that you have taken in the past year to make you

feel good or intoxicated? 1 yes 2 no .

(b) If yes write the name/s of the drug here ………………………………………………….

26 Do you know of any other drug that some of your classmates are taking to make them feel

good or intoxicated? 1 yes 2 no .

(b) If yes what are the drugs called? ………………………………………………………..

27 If you had used any cannabis, would you have mentioned it in this questionnaire? 1. No

2. Not sure 3. Yes

28 Do you know all these drugs are dangerous to health? 1 yes 2 no .

Thank you for responding

115

APPENDIX VII: SOCIAL CLASSIFICATION BY OLUSANYA et al 108

A : FATHER’S OCCUPATION

SCORE

1 Professional, top civil servant, politicians and top business men

2 Middle level bureaucrats, technicians, skilled artisan and well-to-do traders.

3 Unskilled worker and those in general whose incomes are below the minimum wage.

B: MOTHER’S LEVEL OF EDUCATION

SCORE

0 Education up to university

1 Secondary education or tertiary level below university e.g. College of Education, School

of nursing.

2 No schooling or up to primary education.

Social class = Score from A + Score from B

Total score of 1 and 2 = higher socioeconomic class.

Total score of 3 = middle socioeconomic class.

Total score of 4 and 5 = lower socioeconomic class.

116

APPENDIX VIII: ASSESSING THE SERIOUSNESS OF ADOLESCENT DRUG

ABUSE (ASADA) SCORING METHOD.

School…………………………………………….…………………….

Code………………....

VARIABLES SCORE

0 +1 +2

1 Type of drug used None Beer, wine,

local gin,

cigarette,

coffee, kola

nut.

Marijuana, Indian hemp,

cocaine, crack, heroine,

amphetamine,

hallucinogens.

2 Setting of drug abuse Group Alone

3 Affect before drug use Happy Always poor Sad

4 Time of drug use After school Before school

5 Time of week drug is

used

Weekend Week days

6 Use before driving No Yes

7 History of accidents None Yes

8 School performance Good/impr

oving

Always poor Recently poor

9 Positive history of family

drug abuse

No Yes

117

10 Age when drug was first

abused

>15years <15years

11 Sex Male Female

APPENDIX IX: PAEDIATRIC SYMPTOMS CHECKLIST (PSC) – YOUTH REPORT

VERSION

School…………………………………………….…………………….

Code………………....

Please mark under the heading that best describes you;

Never Sometimes Often

1. Complain of aches and pains ____ ____ ____

2. Spend more time alone ____ ____ ____

3. Tire easily, little energy ____ ____ ____

4. Fidgety, unable to sit still ____ ____ ____

5. Have trouble with teacher ____ ____ ____

6. Less interested in school ____ ____ ____

7. Act as if driven by a motor ____ ____ ____

8. Daydream too much ____ ____ ____

9. Distract easily ____ ____ ____

10. Are afraid of new situations ____ ____ ____

11. Feel sad, unhappy ____ ____ ____

12. Are irritable, angry ____ ____ ____

118

13. Feel hopeless ____ ____ ____

14. Have trouble concentrating ____ ____ ____

15. Less interested in friends ____ ____ ____

16. Fight with other children ____ ____ ____

17. Absent from school ____ ____ ____

18. School grades dropping ____ ____ ____

19. Down on yourself ____ ____ ____

20. Visit the doctor with doctor finding nothing wrong ____ ____ ____

21. Have trouble sleeping ____ ____ ____

22. Worry a lot ____ ____ ____

23. Want to be with parent more than before ____ ____ ____

24. Feel that you are bad ____ ____ ____

25. Take unnecessary risks ____ ____ ____

26. Get hurt frequently ____ ____ ____

27. Seem to be having less fun ____ ____ ____

28. Act younger than children your age ____ ____ ____

29. Do not listen to rules ____ ____ ____

30. Do not show feelings ____ ____ ____

31. Do not understand other people’s feelings ____ ____ ____

32. Tease others ____ ____ ____

33. Blame others for your troubles ____ ____ ____

34. Take things that do not belong to you ____ ____ ____

35. Refuse to share ____ ____ ____

119

Total Score -------------------------------------------------

APPENDIX X: SCHOOL DATA/ REPORT

Name of Child…………………………………………….. Code…………………

Class in 2012/2013 Academic Session……………………………………….

Academic Performance 1st Term 2nd Term 3rd Term

I Class Position .......... ……….. ………..

II Overall Score ………. ……….. ………..

III % Score Mathematics ………. ……….. ………..

IV % Score English ………. ……….. ………..

V % Score Igbo ………. ……….. ………..

VI % Score biology ………. ……….. ………..

Total number of days absent from school……… ………. .………

Total for the year……………………………………………………………………

Total No. of students in the Class ……………………………………………………