DEVELOPMENT AND EFFECTIVENESS OF

MASS MEDIA EDUCATION CAMPAIGN ON THE

KNOWLEDGE, BELIEFS, ATTITUDES AND

BEHAVIOUR RELATING TO QAT CHEWING

AND HEALTH RISK AMONG SECONDARY

SCHOOL STUDENTS IN ADEN, YEMEN

by

MOHAMMED SALEH AHMED AL-KAF

Thesis submitted in fulfillment of the requirements

for the degree of

Doctor of Philosophy

October 2017

نج راة والأ توبا عندهمأ في التوأ ي الذي يجدونه مكأ م سول النبي الأ يل يأأمرهم بالأمعأروف وينأهاهمأ الذين يتبعون الر

م عليأهم الأخبائث وي لل التي كانتأ عليأهمأ فالذين عن الأمنكر ويحل لهم الطيبات ويحر غأ رهمأ والأ ضع عنأهمأ إصأ

ئك هم الأمفألحون روه ونصروه واتبعوا النور الذي أنزل معه أول آمنوا به وعز

(157 الاعراف )

DEDICATION

This work is dedicated firstly to my father who nurtured and supported me

throughout his life, may Allah S.W rest his soul in peace, and to my beloved mother

who I still owe her and view the world through her eyes. And my dear wife who lost

her age taking care of my kids; my daughters Maryam and Aishah, sons Ahmed and

Omar, and to my sister Dr.Nadia and her husband, Dr.Musa at Taiba University (

Saudi Arabia), whom supported me financially. Also my thanks go to my sister and

her husband in Aden (South Arabia) for their moral support.

ii

ACKNOWLEDGEMENT

My thanks and appreciation goes to my supervisor Professor Rahmat Bin Awang for

his keenness, patience, encouragement and advice throughout my time as his student,

which will be informative experience to my life and future career. Also, my thanks

go to Dr. Maizurah Omar for her coordination and administrative concerns that

contributed to the accomplishment of my Ph.D degree. I would like to thank my field

supervisor Professor Dr. Huda Basaleem from the Medical Institute and Health

Science (Aden University) and Dr. Khaled Al-Sakkaf as well. I would like to thank

the Teaching and Education Office in Aden city and all the public secondary school

directors and supervisor teachers and students who participated in this work. I must

express my gratitude to the University of Aden for their financial support during my

PhD study.

I would like also to thank the director of the National Poison Center in University

Sains Malaysia and all the staff for their assistance throughout my study. Special

thanks go to Mrs. Lucy Chuah, Miss Afiza, Mr. Ahmad Shalihin and Mr.

Mohammed Nazri for their assistance during my PhD study. Finally, I would also to

thank Aden Free and the Yemeni Health Organizations for the moral support. My

thanks also go to my friends, too many to mention, who contributed in other ways to

the success of this work. All of you Jazakum Allah Khair

iii

TABLE OF CONTENTS

ACKNOWLEDGEMENT…………………………………………………….. ii

TABLE OF CONTENTS……………………………………………………… iii

LIST OF TABLES…………………………………………………………….. x

LIST OF FIGURES……………………………………………………………. xiv

LIST OF ABBREVIATIONS………………………………………………….. xvi

ABSTRAK…………………………………………………………………….. xviii

ABSTRACT…………………………………………………………………… xx

CHAPTER I - BACKGROUND AND JUSTIFICATION

1.1 Introduction into qat chewing phenomena................................................... 1

1.1.1 The history and origin ........................................................................ 1

1.1.2 Chemical components........................................................................ 5

1.1.3 Mechanism of action……………………………………………….. 5

1.1.4 Pharmacological of qat in human beings.......................................... 6

1.1.5 Qat consumption and public health...................................................

1.1.6 Qat related morbidity and mortality..................................................

7

8

1.2 Socio-Economic aspects of qat chewing..................................................... 10

1.2.1 Social norms..................................................................................... 10

1.2.2 Economic aspects............................................................................. 11

1.3 Qat control in Yemen.................................................................................... 12

1.3.1 Qat control in Aden (before unification).......................................... 13

1.3.2 Qat chewing in different cultures..................................................... 14

1.4 Qat chewing and mass media education campaigns in Yemen................... 15

iv

1.5 The history of educational system in Aden city.......................................... 17

1.6 Purpose of the study..................................................................................... 18

1.7 Rationale of the study.................................................................................. 19

1.8 Study hypothesis.......................................................................................... 19

1.9 Study questions............................................................................................ 20

1.10 Study objectives........................................................................................... 20

1.10.1 General objective for the mass media exposure study...................... 20

1.10.2 Specific objectives............................................................................ 20

CHAPTER II - LITERATURE REVIEW AND CONCEPTUAL

FRAMEWORK

2.1 Qat chewing prevalence...............................................................................

22

2.2 Health adverse effects of qat chewing on humans……………………….. 25

2.2.1 Physical and psychological effects…………………………………. 25

2.2.2 Qat chewing and oral health problems……………………………... 28

2.2.3 Qat chewing and cardiovascular system problems............................. 32

2.2.4 Qat chewing and gastrointestinal tract problems................................ 33

2.2.5 Qat chewing and reproductive system……………………………… 36

2.3 Knowledge, beliefs and attitudes related to qat consumption……………

38

2.4 Measures the impact of anti-drug abuse mass media campaigns...............

40

2.5 Drug abuse initiation among adolescents..................................................

44

2.6 Evaluating adolescents-based anti-substance abuse mass media............... 45

CHAPTER III - MATERIALS AND METHODS

3.1 Introduction................................................................................................. 50

3.1.1 Study location.................................................................................... 50

v

3.2 Cross-sectional study (Part I)....................................................................... 51

3.2.1 Study design………………………………………………………..

51

3.2.2 Sample size and sampling procedure............................................... 51

3.2.3 Data collection method.................................................................... 52

3.2.4 Study variables................................................................................. 52

3.2.5 Statistical analysis............................................................................. 53

3.3 Pre-test and Post-test study (Part II)……………………………………… 54

3.3.1 Study design……………………………………………………… 54

3.3.2 The control and intervention groups………………………………. 54

3.3.3 Stages of the intervention…………………………………………. 55

3.3.4 The main outcome measures……………………………………… 55

3.3.5 Study population.............................................................................. 55

3.3.5(a) Inclusion criteria……………………………………....... 56

3.3.5(b) Exclusion criteria………………………………………. 56

3.3.6 Sample size estimation and calculation……………………….. 56

3.3.6(a) Sample size calculation……………………………… 56

3.3.6(b) Sample size selection………………………………... 57

3.3.6(b)(i) Selection of districts in Aden city………. 57

3.3.6(b)(ii) Selection of required schools……………. 59

3.3.6(b)(iii) Selection of required students…………..

60

3.3.6(b)(iv) Allocation of participates in each……….

control. and intervention groups

62

3.3.7 Study tools..................................................................................... 64

3.3.7(a) Questionnaire development and administration………. 64

vi

3.3.7(a)(i) Translation of questionnaire………………

3.3.7(a)(ii) Piloting the questionnaire………………

64

65

3.3.7(b) Mass media tools and validity of the program................. 65

3.3.8 Outcome measures of the study…………………………………. 66

3.3.9 Measurements of the study domains……………………………. 66

3.3.9(a) Exposure to the anti-qat mass media messages................ 66

3.3.9(b) Knowledge measurement………………………………. 67

3.3.9(c) Beliefs and attitudes measurements……………………. 67

3.3.9(d) Students behavior……………………………………..

3.3.10 Data collection …………………………………………………

67

68

3.3.11 Campaign process........................................................................... 68

3.3.11(a) Organizing school's staff roles…………………………. 68

3.3.11(b) Organizing active students’ roles in the intervention…...

schools

69

3.3.12 Health promotion activities……………………………………….. 69

3.3.12(a) Messages used in the campaign....................................... 70

3.3.12(b) Images related to messages (posters, sticker cards and...

wall magazines)

71

3.3.12(c) Tagline............................................................................. 71

3.3.12(d) Logos............................................................................... 71

3.3.13 Duration of the campaign………………………………………… 72

3.3.13(a) First month program (Feb 2014)……………………….. 72

3.3.13(a)(i) Educational program……………………... 72

3.3.13(a)(ii) Billboards session....................................... 75

3.3.13(b) Second month program (March 2014)………………….. 80

3.3.13(b)(i) Posters session……………………………..

80

vii

3.3.13(b)(ii) Brochures session........................................ 92

3.3.13(b)(iii)Wall magazines session............................... 92

3.3.13(c) Third month program (April 2014)……………………... 95

3.3.14 Data analysis……………………………………………………… 97

3.3 Flow chart of data collection……………………………………………. 98

3.4 Official approval of the study ………………………………………….. 99

CHAPTER IV- RESULTS

4.1 The socio-demographic characteristics (Part I) ..........................................

4.1.1 Current prevalence of qat chewing among adolescents...................

100

102

4.1.2 Qat chewing and associated risk factors......................................... 104

4.2 The general demographic characteristics (Part II).......................................

108

4.2.1 Current qat chewing status and experimentation of.......................

qat chewing history

111

4.2.2 Social norms and their acceptability of qat chewing......................

among family and friends

112

4.2.3 Students’ opinion and intention on qat chewing and cessation......

114

4.2.4 Initiation to qat chewing..............................................................

114

4.2.5 The social situations and restrictions of qat chewing...................

among household

115

4.2.6 Sources of possessing and obtaining qat.....................................

116

4.2.7 Purchasing qat.............................................................................. 117

4.2.8 Qat chewing and the addictive behaviour.................................... 118

4.2.9 First time chew qat (starting chew age)....................................... 119

4.2.10 Initiation of chewing qat..............................................................

120

4.2.11 Beliefs about quitting qat chewing..............................................

120

4.2.12 Types of cessation........................................................................

121

viii

4.3 Exposure to anti-qat mass media messages..............................................

123

4.3.1 Salience (Noticing and Reading) and level of exposure..............

123

4.3.2 Qat chewers and non-qat chewers’ salience.................................

and exposure level to mass media

129

4.3.3 Students mass media scores......................................................... 135

4.3.4 Male and female salience............................................................. 137

4.3.5 Secondary school students’ perception related-mass...................

media messages after the program

143

4.4 Secondary school students’ response to knowledge questions................. 147

4.4.1 Control and intervention groups’ response.................................. 147

4.4.2 Qat chewers and non-qat chewers’ response............................... 151

4.4.3 Male and female response to knowledge..................................... 155

4.4.4 Level of knowledge.......................................................................

159

4.4.5 Knowledge scores before and after the program............................

163

4.4.6 The association between knowledge and socio-demographics......

165

4.5 Students’ beliefs about qat chewing..........................................................

167

4.5.1 Pro-qat chewing beliefs (control vs. intervention) ........................

167

4.5.2 Pro-qat beliefs among qat chewers and non-qat chewers.............

in the intervention groups

171

4.5.3 Anti-qat chewing beliefs (control vs. intervention)...................... 175

4.5.4 Anti-qat chewing beliefs of qat and non-qat chewers................

in the intervention group

179

4.5.5 Pro and anti qat chewing beliefs scores........................................ 183

4.6 Students’ attitudes about qat chewing......................................................

185

4.6.1 Students attitudes (control vs. intervention)……………………..

185

4.6.2 Qat chewers and non-qat chewers’ attitudes.................................. 187

4.7 The overall behaviour of students............................................................... 189

ix

CHAPTER V- DISCUSSION

5.1 Prevalence of qat chewing (Part I) ..............................................................

191

5.2 Mass media education campaign (Part II)................................................... 194

5.2.1 Characteristics of students’ in the control and.................................

intervention groups

194

5.2.2 Exposure to anti-qat mass media campaign..................................... 197

5.2.2(a) Salience to mass media messages..................................... 197

5.2.2(b) Response to the anti-qat mass media messages................ 200

5.2.3 The impact of mass media campaign on students’ knowledge.........

201

5.2.4 Outcome of mass media campaign on pro-and-anti.........................

qat chewing beliefs

206

5.2.5 Impact of mass media campaign on attitudes..................................

208

5.3 Limitation of the study................................................................................ 211

CHAPTER VI- CONCLUSION AND RECOMMENDATIONS

FOR FUTURE RESEARCH

6.1 Summary of the study................................................................................ 212

6.2 Study recommendation.............................................................................. 213

6.2.1 Recommendation for future research............................................ 213

6.2.2 Recommendation to the Yemeni government.............................. 214

REFERENCES 215

APPENDICES

LIST OF PUBLICATIONS

x

LIST OF TABLES

Page

Table 2.1

Estimated prevalence of qat chewing using samples of

younger age groups

25

Table 3.2

Selection of districts 58

Table 3.3a

Selection of intervention schools from intervention districts 60

Table 3.3b

Selection of control schools from control districts 60

Table 3.4a

Required number of male and female from intervention

schools

61

Table 3.4b

Required number of male and female from control schools 62

Table 3.5a

Allocation of participants to the intervention schools 63

Table 3.5b

Allocation of participants to the control schools 63

Table 3.6 Numbers of media tools used in the intervention schools 96

Table 4.1 Socio-demographic characteristics (cross sectional study) 101

Table 4.2 Current prevalence of adolescents' qat chewing 103

Table 4.3 Association of risk related-factors with qat chewing 105

Table 4.4 Predictors of adolescents' qat chewing 107

Table 4.5 Socio-demographic profile (mass media study) 110

Table 4.6 Current qat chewing status and experimentation 111

Table 4.7 Norms and the acceptability of chewing qat 113

Table 4.8 Secondary school students’ opinion, intention and cessation 114

Table 4.9 Secondary school students’ initiation to chew qat 115

Table 4.10 Social situation and restrictions of qat chewers 116

Table 4.11 Source of obtaining qat in the control and the intervention 117

Table 4.12 Qat purchasing characteristics 118

Table 4.13 Addictive behaviour of qat 119

xi

Table 4.14

First time started chewing qat (age) 119

Table 4.15 First time chewing qat (initiation) 120

Table 4.16 Attempts to quit chewing qat 121

Table 4.17 Qat chewers’ cessation help 122

Table 4.18 Differences in salience 124

Table 4.19 Differences in exposure level to mass media channels 126

Table 4.20 Changes in exposure level to mass media 128

Table 4.21 Differences in salience between qat and non-qat chewers 130

Table 4.22 Differences in exposure level to mass media channels in the qat chewers

and non-qat chewers

132

Table 4.23 Changes in the exposure level to salience of qat chewers and

non-qat chewers

134

Table 4.24

Differences in mass media scores between secondary school

students (control vs. intervention)

136

Table 4.25

Differences in salience to mass media in male and female in

the intervention group

138

Table 4.26

Differences in exposure level to mass media channels in the

male and female in the intervention group

140

Table 4.27

Changes in salience and exposure level of mass media in male

and female in the intervention group

142

Table 4.28

Perception of students in the control and the intervention groups after the

impact of mass media messages

144

Table 4.29

Perception of qat chewers and non-qat chewers in the

intervention groups after the impact of mass media message

146

Table 4.30

Differences in qat chewing-related knowledge between the

secondary school students in the control and the intervention

groups

148

Table 4.31

Changes in qat chewing-related knowledge in secondary

school students in the control and the intervention groups

150

Table 4.32

Differences in qat chewing-related knowledge between the qat

chewers and non-qat chewers in the intervention group

152

xii

Table 4.33 Changes in qat chewing-related knowledge for qat chewers

and non-qat chewers in the intervention group

154

Table 4.34

Differences in qat chewing-related knowledge between male

and female students in the intervention group

156

Table 4.35

Changes in qat chewing-related knowledge in male and

female students in the intervention group

158

Table 4.36

Level of knowledge in the control and intervention groups 160

Table 4.37

Level of knowledge among male students in the control and

the intervention groups

160

Table 4.38

Level of knowledge among female students in the control and the

intervention groups

160

Table 4.39

Level of knowledge among male qat chewers in the control

and the intervention groups

162

Table 4.40

Level of knowledge among male non-qat chewers in control and the

intervention groups

162

Table 4.41

Level of knowledge of female non-qat chewers in the control

and the intervention groups

162

Table 4.42

Total scores of knowledge in the control and the intervention

groups

164

Table 4.43

Relationship between the students’ characteristic in the

intervention group and qat chewing related knowledge

166

Table 4.44

Differences in pro-qat beliefs among secondary school

students in the control and the intervention groups

168

Table 4.45

Changes in pro-qat chewing beliefs in the control and

intervention groups

170

Table 4.46

Differences in pro-qat beliefs among qat chewers and non-qat

chewers in the intervention group

172

Table 4.47 Change on the pro-qat chewing beliefs among qat-chewers

and non-qat chewers in the intervention group

174

Table 4.48

Differences in anti-qat beliefs between the control and the

intervention groups

176

Table 4.49

Changes in anti-qat chewing beliefs in the control and

intervention group

178

xiii

Table 4.50

Differences in anti-qat chewing beliefs between qat chewers

and non-chewers in the intervention group

180

Table 4.51

Changes in anti-qat chewing beliefs in the qat chewers and

non-qat chewers in the intervention group

182

Table 4.52

Differences in scores in pro and anti qat beliefs between

secondary school students in the control and the intervention

groups

184

Table 4.53

Differences in attitudes between the control and the

intervention groups

186

Table 4.54 Change in attitudes in the control and the intervention groups 186

Table 4.55

Differences in qat chewers and non-qat chewers in the

intervention group attitudes

188

Table 4.56

Change in qat chewers and non-qat chewers attitudes in the

intervention group

188

Table 4.57

Changes in qat chewers’ behaviour in the control and the

intervention groups

190

xiv

LIST OF FIGURES

Page

Figure 1.1 Qat profile in Yemen 4

Figure 2.1 Conceptual framework of the study 43

Figure 3.1 The districts in Aden city 50

Figure 3.2

The intervention and control districts in Aden city the red spots

represent the intervention districts and the green spots represent

the control districts

59

Figure 3.3

Figure 3.4

Campaign logo

Lictures and seminars in male and female schools

71

74

Figure 3.5 Posted in the male Al-Nahda secondary school 75

Figure 3.6 Posted in the female secondary school, Abdulbary 76

Figure 3.7 Posted in the female secondary school, Balqees 77

Figure 3.8

Posted in the male secondary school wall (Abdo-ghanem) 78

Figure 3.9 Mounted on the male secondary school wall (Abdo-ghanem) 79

Figure 3.10

Environmental message: the message was related to the

important resources water "القات يستهلك مائنا"

81

Figure 3.11 Religious messages 82

Figure 3.12 Health message depicting a set of damaged teeth 83

Figure 3.13

Health message (A) warns that qat consumption can cause

cancer. (B) male student reading the health message on the

sticker card

84

Figure 3.14

Health message warning that qat consumption can lead to liver

cancer

85

Figure 3.15

Health related message (A) Qat and constipation (B) Qat and

stomach ulcer

86

Figure 3.16

Health related message (A) Qat a cause for heart attack and

brain strokes (B) Qat and unstable blood pressure

87

Figure 3.17 Health warning message on qat and diabetes mellitus 88

xv

Figure 3.18 Health, neurological disorders related messages qat can lead to

aggressive behaviour among family members

89

Figure 3.19 Health, economic and social. Qat can lead to poverty

90

Figure 3.20

Health, social and economic. Qat can lead to malnutrition

91

Figure 3.21 Two samples of brochures used in the campaign and distributed

to students

92

Figure 3.22 Wall chart. No to QAT "لا للقات" messages on wall charts in

female schools

93

Figure 3.23 Wall chart. No to QAT "لا للقات" messages on wall charts in

male schools

94

Figure 3.24 Flow chart of the study 98

Figure 4.1 Flow chart of study subjects 108

xvi

LIST OF ABBREVIATIONS

AMI Acute Myocardial Infarction

ALT Alanine Amino-Transferase (liver enzyme)

ALP Alkaline Phosphatase (liver enzyme)

AST

Aspartate Trans-Aminase (liver enzyme)

BMI Body Mass Index

CNS Central Nervous System

DDT Dichlorodiphenyltrichloroethane

ECG Electro-Cardio-Gram

EMCDD

European Monitoring Centre for Drugs and Drug Addiction

GCC Gulf Cooperation Council

ITC

ICU

International Tobacco Control

Intensive Care Unit

IBM International Business Machines

MBP Mean Blood Pressure

NGOs Non-Governmental Organization

NIDA

NPSAD

National Institute on Drug Abuse

National Programme on Substance Abuse Deaths

PDRY People’s Democratic Republic of Yemen

SCL-90 Symptoms Check-List-90

SRS

Simple Random Sampling

USA United States of America

UK United Kingdom

UAE United Arab Emirates

xvii

UNICEF United Nations Children's Fund

UNNL

UNODC

United Nations of Narcotics Laboratories

United Nations Office on Drugs and Crime

USM Universiti Sains Malaysia

WHO World Health Organization

YAR Yemen Arab Republic

xviii

PEMBANGUNAN DAN KEBERKESANAN KEMPEN PENDIDIKAN

MELALUI MEDIA MASSA TERHADAP PENGETAHUAN,

KEPERCAYAAN, SIKAP DAN TINGKAHLAKU BERKAITAN

PENGUNYAHAN QAT DAN RISIKO KESIHATAN DALAM KALANGAN

PELAJAR SEKOLAH MENENGAH DI ADEN, YAMAN.

ABSTRAK

Qat (Catha edulis) merupakan satu spesies tumbuhan yang digolongkan

dalam famili Celastraceae. Pengunyahan qat adalah amalan biasa di rantau Afrika

Timur dan Semenanjung Arab sejak 11 abad yang lalu. Daun segar dan tunas

tumbuhan tersebut mengandungi katinon dan katin sebagai bahan aktif. Katinon

adalah bahan perangsang menyerupai amfetamina yang bertanggungjawab terhadap

kebanyakan tindakan farmakologi qat. Antara kesan qat adalah untuk meningkatkan

tumpuan, dan ini telah digunakan sebagai alasan oleh para pelajar untuk mengunyah

qat. Satu kajian keratan lintang telah dijalankan bertujuan untuk mengenalpasti

prevalens pengunyahan qat dalam kalangan remaja diikuti oleh kajian rekabentuk

kawalan eksperimen pra-dan pasca-ujian untuk menilai kesan kempen pendidikan

melalui media masa terhadap pengetahuan, kepercayaan, sikap dan tingkahlaku

pengunyahan qat dalam kalangan pelajar sekolah menengah awam di bandar Aden,

Yaman. Dalam bahagian pertama kajian ini, prevalens pengunyahan qat dalam

kalangan pelajar sekolah menengah di bandar Aden adalah 19.9%. Rakan sebaya,

lelaki (jantina), tempat kelahiran, umur dan kepercayaan adalah peramal kepada

pengunyahan qat. Dalam bahagian kedua kajian ini, kempen anti-kunyah qat yang

terdiri daripada bahan audiovisual seperti papan iklan, poster, risalah, majalah

xix

gantungan dindingsiaran radio sekolah, filem dokumentari, kad pelekat dan lakaran,

serta kuliah dan seminar, telah diperkenalkan selama tiga bulan dan penilaian dibuat

menggunakan eksperimen pra dan pasca-ujian melibatkan pelajar sekolah menengah

awam gred kedua (ke-11) di bandar Aden, Yaman yang dibahagikan kepada

kumpulan kawalan dan intervensi. Kajian mendapati bahawa pelajar sekolah

menengah dalam kumpulan intervensi (89.9%) adalah lebih terdedah kepada mesej

media massa anti-kunyah qat berbanding kumpulan kawalan (44.5%) selepas

pendidikan semula dan ini meningkatkan tahap kesedaran berkaitan risiko kesihatan

mengunyah qat serta menambahbaik tahap kepercayaan dan sikap. Pada

keseluruhannya, pengetahuan, kepercayaan dan sikap pelajar sekolah menengah

dalam kumpulan intervensi meningkat dengan signifikan. Walau bagaimanapun,

perubahan tingkah laku dalam kalangan pelajar terhadap mengunyah qat masih tidak

jelas. Sebilangan besar remaja yang telah terdedah kepada mesej media massa

percaya bahawa kempen anti-kunyah qat berkait rapat dengan mereka. Mereka

faham daripada kempen tersebut, bahaya mengunyah qat, dan mengurangkan

kebarangkalian mereka untuk memulakan tabiat mengunyah qat pada masa hadapan.

Kesan kempen adalah lebih ketara dalam kalangan bukan pengunyah qat berbanding

pengunyah dan dalam kalangan pelajar perempuan berbanding lelaki. Secara

keseluruhannya, kajian ini menunjukkan keberkesanan kempen pendidikan melalui

media massa, khususnya kepentingan dan pengaruhnya terhadap pengetahuan,

kepercayaan dan sikap remaja. Walau bagaimanapun, kesannya terhadap tingkah

laku tidak diperhatikan, dan ini mungkin disebabkan oleh tempoh kajian yang

pendek.

xx

DEVELOPMENT AND EFFECTIVENESS OF MASS MEDIA EDUCATION

CAMPAIGN ON THE KNOWLEDGE, BELIEFS, ATTITUDES AND

BEHAVIOUR RELATING TO QAT CHEWING AND HEALTH RISK

AMONG SECONDARY SCHOOL STUDENTS IN ADEN, YEMEN

ABSTRACT

Qat (Catha edulis) is a species belonging to the plant family Celastraceae.

Qat is commonly chewed throughout East Africa and the Arabian Peninsula since the

11th century. The fresh leaves and buds of the plant contain cathinone and cathine as

the active substances. Cathinone is an amphetamine like stimulant responsible for

most of its pharmacological action. Among them, is enhancing concentration, and

this has been used as a reason for the students to consume qat. A cross-sectional

study was carried out aimed at determining the prevalence of qat chewing among

adolescents followed by a pre-test post-test experimental control design study aimed

at evaluating the outcome of mass media educational campaign on the knowledge,

beliefs, attitudes and behavior of qat chewing health risk among public secondary

school students in Aden city, Yemen. In the first part of the study, the prevalence of

qat chewing among secondary school students in Aden city was found to be 19.9%.

Friends, male (gender), place of origin, age and beliefs were the predictors of qat

chewing. In the second part of the study an anti-qat chewing campaign consisted of

audiovisual material such as billboards, posters, brochures, wall magazines, school

radio, documentary movie, sticker cards and sketch, as well as lectures and seminars

were introduced for three months and evaluated using a pre-test and post-test

experiment consisting of control and intervention groups on second grade (11th)

xxi

public secondary school students in Aden city, Yemen. The study found that

secondary school students in the intervention group (89.9%) were more exposed to

the anti-qat chewing mass media messages than the control group (44.5%) after re-

education resulting in greater level of awareness about health risk of qat chewing and

improved beliefs and attitudes. The overall knowledge, beliefs and attitudes of the

secondary school students in the intervention group were raised significantly.

However, the behaviour change of students towards qat chewing was not evident. A

significant number of adolescents who had been exposed to the mass media

messages believed that the anti-qat chewing campaign relates closely to them. They

understood from the campaign the dangers of chewing qat, and reduce their

likelihood of acquiring or taking up the habit of chewing qat in the future. The effect

of the campaign is more pronounced in non-qat chewers than qat chewers and female

more than male students. Overall, this study demonstrated the efficacy of the mass

media educational campaign, with respect to salience and its effects on adolescents’

knowledge, beliefs and attitudes. However, its effect in behaviour was not observed,

but this could be due to the short duration of the study.

1

CHAPTER I

BACKGROUND AND JUSTIFICATION

1.1 Introduction into qat chewing phenomena

1.1.1 The history and origin

The history of qat chewing can be traced back to as early as the fourteenth

century in the horn of Africa especially in Ethiopia. A sources of ancient Arabs claim

that qat originated from the highlands of Ethiopia and found its way to Yemen

(Gebissa, 2010). In Yemen, the qat tree was named and described by the Swedish

Botanist and Neutralist Peter Forsk (1732-1763), who had travelled to Yemen to

collect some botanical and zoological specimens. Qat was one of the specimens that

he found there. Forsk was died in Yemen by malaria disease. His companion Carsten

Niebuhr (1736-1815) who was expedition had termed qat in his first botanical

published under the generic name of Catha edulis Forsk in memory of his friend

(Greenway, 1947).

Qat is chewed to enhance concentration, reduce hunger and fatigue, and as

traditional remedies to cure venereal disease, asthma, cold, fever, cough and

headaches (Elmi, 1983; Kalix, 1984). This phenomenon is fostered with religious

ceremonies during worship, prayers and other religious affairs. By the sixteenth

century, qat chewing had spread into the various strata of the Yemeni society raising

legal and religious concern (Ward and Gatter, 2000).

Qat tree which belongs to the Celastraceae family is cultivated and harvested

in Ethiopia, Yemen, Somalia and Kenya (Halbach, 1972). It is perennial species and

thriven in the wet highlands lasting more than 50 years. This characteristic makes qat

a profitable crop (Kalix and Glennon, 1986). Qat is known by various names in the

2

western literature: Qat, khat, Chat, Qaad, Jaad, Miraa, Mairangi, Cat, Flower of

Paradise, Tohai, African salad, and Catha and Tea of the Arabs (Kalix, 1990).

Advancement in transportation in the last two decades enabled qat to find its

way into some Arab countries, Europe, North America, India and even Australia

(Klein et al., 2012). In recent years qat cultivation has expanded to new territories to

Somalia, Djibouti, Tanzania, Uganda, Zimbabwe and Zambia, as well as Afghanistan

and Turkistan (Halbach, 1972; Cox and Rampes, 2003). In Islamic countries like

Yemen, Somalia, Ethiopian and Kenyan, qat chewing is prevalent among the local

Muslims, considers legal unlike alcohol which is prohibited. Saudi Arabia, however

bans qat chewing citing religious and economic reasons whereas in Yemen, even

religious leaders practice this habit to induce milder antisocial behavior as oppose to

narcotics that is unacceptable (Dhaifalah and Santavy, 2004).

The general pharmacological effects of qat chewing due to presence of

cathinone and cathine include high blood pressure, enhance pulse rate, euphoria,

depression and insomnia followed by constipation, anorexia, gastritis and lack of

libido (Kalix, 1983). An updated report conducted in Yemen shown that long term of

qat consumption may lead to psychosis disorders (El-Guneid, 1991). Because of its

many repercussions on health, a number of European countries have banned qat

import for negative social and economic reasons (Dhaifalah and Santavy, 2004).

In June 2014, because of drug misuse, the United Kingdom banned the

import of qat, placing and scheduled it as class C an illegal drug. Likewise

Netherlands and some other European countries followed the British example and

prohibited qat chewing and its sale (Drugs and Addiction, 2014). Despite the

negative consequences of qat chewing imposes on health and its social and economic

implications, its consumption and usage remain a popular trend in Yemen, including

3

very remote areas. In the mid-1980s, the prevalence of qat usage was 85% for male

and 60% for female in the north Yemen. After the unification, the chewing habit

spread to the south of Yemen and evolved from occasional usage to everyday

consumption (Ward and Gatter, 2000). Basunaid et al. (2008) reported the

prevalence of qat chewing among Yemeni male and female to be about 80% and

60% respectively. According to the World Bank Report Qat Consumption Survey in

Yemen 2006, the prevalence of qat chewing among male and female was 73% and

33% respectively (Milanovic, 2008). Astonishingly, 15 to 20% children less than 12

years were found to be daily qat chewers (Mugahed, 2008).

Qat consumption plays a major role in Yemen’s economy and represents 10%

of consumption and one-third of agriculture of gross domestic product (Ward and

Gatter, 2000). It was also reported that qat consumers spent approximately half of

their monthly income for purchase of the product and parents spend 4 to 5 hours a

day joining other qat chewers away from their homes, thus neglecting their children’s

welfare and supervision of their education, leading to an illiterate generation (Al-

abed et al., 2014).

In Yemen, qat consumption particularly among children, have not yet been

investigated although some studies have covered limited population groups

(Bawazeer, 1993). This study aims to evaluate the efficacy of an anti-qat chewing

mass media education campaign based on knowledge, beliefs, attitudes and

beahviour of secondary school students in Aden city, Yemen.

It hopes that the outcome of this effort will be able to convince relevant

authorities to institute policy change on the use of qat. It has the potential to provide

schools, communities, cities, regions and countries with useful information to

develop appropriate early measures to combat qat cultivation, production and

4

consumption and in doing so, protect the public and the environment from

destruction and waste (Figure 1.1).

A) Qat Sellers

B) Qat cultivation

C) Stalks and leafs of qat

D) Yemeni youths chewing qat

Figure 1.1 Qat profile in Yemen (All pictures are reproduced from the internet: http://en.wikipedia.org/wiki/khat)

5

1.1.2 Chemical components

The United Nations of Narcotics Laboratories (UNNL) in 1975 isolated the

main constituent called cathinone which analogue amphetamine a psycho-stimulant

substance. Qat contains more than 40 alkaloids, glycosides, tannis, amino acids,

vitamins and minerals (Elmi, 1983; Abdulwaheb and Abebe, 2007). The major

active ingredients in a qat leaf was identified as the phenyl alkyl amine(-)-alpha

amino-propiophenone named cathinone and cathine (nor-pseudo-ephedrine) (Kalix,

1984).

The fresh qat leaves after picking contain a higher proportion of cathinone.

During the drying process cathionone is converted into cathine, which has milder

effects than cathinone (Milanovic, 2008). To obtain better stimulation, chewers have

to continually chew fresh leaves. Similarly to the amphetamine the cathinone exert

its effects throughout neurochemical pathway: dopamine and noradrenalin as well as

cathinone may release serotonin in the CNS (Numan, 2012).

1.1.3 Mechanism of action

Cathinone or alpha-amino-propiophenon is considered as the most active

ingredient of the qat plant, since its effect has been shown to be similar to

amphetamine. Cathine nor-pseudoephedrine or phenylpropanolamine, isolated from

the Ephedra plant has similar effects of qat components, cathine has milder psycho-

stimulant action than cathinone. Fresh green leaves contain a higher proportion of the

desirable cathinone. Cathinone, because of its instability, breaks down during drying

into cathine which is less powerful than cathinone. It releases dopamine in the

striatum and nucleus accumens shell of similar potency to amphetamine in low

concentrations (Kalix, 1980; Kalix, 1983). Cathinone, in contrast, has more rapid

6

and intensive action that explains its high lipid solubility facilitating access into the

CNS. Because it offers better stimulation, users prefer to chew fresh qat leaves

continually (Cox and Rampes, 2003; Halbach, 1972; Brenneisen et al., 1990; Al-

Motarreb et al., 2010; Kalix, 1987; Patel, 2000; Kalix, 1994).

1.1.4 Pharmacological of qat in human beings

Qat is a psychotropic drug having the amphetamine-like substance called

cathinone. Both have the similar reaction on the brain. Cathinone has the ability to

pass through the brain carrier and induced euphoria, increased alertness,

hyperactivity, excitement, aggressiveness, anxiety and obsessive behaviour. A

depression phase of malaise, lack of concentration, usually follows (Cox and

Rampes, 2003; Al-Motarreb et al., 2002; Hassan et al., 2002). According to

Luqman and Danowski (1976), the green leaves of qat with tiny tips contains

cathinone and cathine, which is capable of inducing; stomatitis, oesophigitis, gastritis

and constipation due to the presence of tannins in the gastrointestinal tract.

As for the genitourinary and reproductive system, cathinone reduces urine

flow rate and is a cause for spermatorrhoea and erectile dysfunction. It is also

reducing libido. Studies have shown the significant incidence of low birth-weight of

full-term infants in the offspring of women who used qat during pregnancy (Kalix

and Braenden, 1985; Kalix, 1990; Hassan et al., 2007; Patel, 2000).

The consumption of large amounts of qat can lead to behavioural hypomania

and psychosis syndromes, such as mania, schizophrenia, paranoid psychosis and

symptoms of acute schizophrenia (Odenwald et al., 2005). The World Health

Organization (WHO) commission on Narcotics Drugs has reported qat consumption

since 1946. Because of the qats biological and social effects, and vague scientific

7

literature of its chemical reactions, it was placed under the list of dangerous and

banned drugs by the WHO in the 1980s (Kennedy et al., 1980; Hassan et al., 2003).

In recent years, even young children and secondary school students in Yemen

have taken up qat chewing. Students appear to have the notion that chewing qat aids

their ability to concentrate better, hence better performance in their studies. It is

important, therefore, to evaluate this perception since qat usage has become a

widespread habit in the Yemeni society. There is a need to understand what attracts

people to this habit, the magnitude of this phenomenon, and how this seemingly

harmless culture can be a bane to the nation’s social and economic well-being.

1.1.5 Qat consumption and public health

According to the reports of United Nations Office on Drugs and Crime

(UNODC), qat chewing has reached a proportion that warrants public and health

concern, and recently there is an accepted view that qat chewing, like other substance

abuse, could ultimately affect the users health (Drugs and Crime, 2010; Dependence,

2003; WHO, 2006) . The widespread prevalence of qat chewing reportedly ranges

between 4.3% to 84% in countries where qat originate and elsewhere available

(Elmi, 1983; Bhui et al., 2003). Literature has suggested that qat chewing is

detrimental not only to the health but socio-economically as well (Al-Motarreb et al.,

2005; Kassim and Croucher, 2006). Qat chewing may also lead to dependence, as

recently suggested by (Griffiths, 1998; Odenwald, 2007; Kassim and Croucher,

2006).

In Yemen, there is an absence of vital indicators on the contributory factors

of poverty, low participation in education particularly among girls, high rate of

illiteracy and proper sanitation. Also lacking is the medical knowledge and initiatives

8

to tackle public health issues among which, is qat chewing.This inadequacy could

possibly bring about greater damage to the national health and economy (Ward and

Gatter, 2000). Qat chewing should be viewed as a potential threat to public health.

It can, however, be curtailed through partnerships and collaborations among the

strata of the general community that should ideally include policy makers, workers,

educators, NGOs and health researchers and other related professionals (Douglas et

al., 2011).

One of the ways to counter qat usage may be in the form of health promotion

activities in the form of campaigns to increase the public’s knowledge and

understanding on the dangers of qat chewing, particularly in communities where this

activity is rampant. The campaign could also incorporate and promote harm-

reduction strategies through educational programs (Douglas et al., 2011).

1.1.6 Qat related morbidity and mortality

As for the physical, pharmacological and psychological effects of qat on

humans, there are some issues in classifying the risk associated with drug morbidity.

In Yemen and other qat producing countries, there is scant literature on the morbidity

and mortality of qat use due to the lack of documented information and insufficient

quantitative research (Gatter, 2006).

Morbidity relating to qat chewing was discussed in some recent literature

encompassing cultivation to consumption (Corkery et al., 2011). Death linked to qat

chewing is traceable in every stage of the plant journey, from its cultivation,

consumption and the effects in the human body. Date et al. (2004) reported that qat

chewers who do not wash the qat leaves before consuming may ingest pesticides

leading to cancer of the digestive system and kidney failure.

9

Corkery et al. (2011) documents reported deaths caused by poisoning from

ingestion of pesticides and fertilisers used in the cultivation of qat. In Ethiopia, Daba

et al. (2011) found excessive levels of pesticide residues such as, Diazinon and DDT

in qat leaves which are linked to oral and oesophageal cancers in various qat

producing areas. Sudden death was linked due to the use of other pesticides such as

Dimethoate. However this was attributed to the accumulation of acetylcholine in the

heart and brain muscles that may lead to bradycardia and cardiac arrest, as several of

qat chewing fatalities (Daba et al., 2011; Corkery et al., 2011).

Despite increasing qat consumption-related deaths in Yemen, no documented

literature or research has looked into this matter. There exist only isolated reports in

Yemen on deaths of individuals due to choking on qat. Yemen reported the death of

an 11-years old boy when a chewed qat was lodged in his trachea and could not be

ejected despite repeated coughing (Mugahed, 2008). The UK National Programme

on Substance Abuse Deaths (NPSAD) also reported a number of deaths due to

medical complication related to qat consumption.

Ghodse et al. (2013) identified and described causes of qat-related deaths.

They suggest that no deaths associated with qat toxicity and overdose have been

reported,but cases due to its toxic effects are now known and confirmed (George’s,

2010). According to the National Programme on Substance Abuse Deaths Report,

Corkery et al. (2011) revealed that there were fifteen qat related deaths (14 male and

1 female) in various hospitals in the UK. The roles of qat in death are the prolonged

use with other substnance of abuse such as alcohol or tobacco, traumatic suicide,

psychosis and hepatic necrosis. Most of the victims were from Somalian and Eretrian

immigrants residing in the UK.

10

1.2 Socio-Economic aspects of qat chewing

1.2.1 Social norms

According to Borelli (2005), essentials factors such as social and economic

generally influence the level an individual consuming qat. Notwithstanding this, qat

is sometimes consumed in significant amount due to “social pressure”, e.g. at a qat

chewing party where the pressure or the temptation to use the substance may be

unusually high. Qat chewing is a factor to socio-economic problems due to loss of

work hours, reduced economic production, malnutrition and diversion of money to

buy excessive quantities of qat (Kassim et al., 2010).

Traditionally, qat chewing is common in the Horn of Africa and the Arab

Peninsula. The chewing process involves the picking of the soft leaves of qat that are

then placed inside the cheek. After chewing, the leaves remain in the mouth. The

leaves extract mixed with saliva is then swallowed. The consumption produces a

sense of euphoria and excitement due to the cathinone effects. In a traditional social

setting, qat chewers are likely to conduct this activity in one of the homes of a fellow

chewer, usually in the afternoon. Each chewer comes with his own supply of qat.

They laze on cushions while indulging in this pastime that might also include

smoking water pipes, cigarettes, sweet beverages and coffee. A gathering of this

nature may have as many as twenty chewers at one time such sessions are perceived

by qat users as promoting social interactions (Luqman and Danowski, 1976; Ward

and Gatter, 2000; Ageely, 2008; Milanovic, 2008; Baasher and Sadoun, 1983).

Students, workers and especially long distance drivers chew qat to obtain the

stimulant effect, purportedly to keep them alert and enhance work capacity (Halbach,

1972; Kalix and Braenden, 1985; Toennes et al., 2003). An informal report from qat

producing countries even suggests that qat chewing is a remedy for treating asthma,

11

depression and abating hunger and fatigue (Luqman and Danowski, 1976;

Al‐ Motarreb et al., 2002; Dhaifalah and Santavy, 2004). In Ethiopia and Yemen,

qat chewing is common among the communities. One of the factors that contribute to

the widespread chewing is an absence of policy on the cultivation and production of

qat (Ward and Gatter, 2000). A World Bank Report has mentioned that qat chewing

has even become prevalent among women of different backgrounds in qat-producing

countries (Griffiths, 1998; Patel et al., 2005).

1.2.2 Economic aspects

In the 17th and 18th century, Yemen’s coffee was a highly sought after

commodity, but its popularity gradually declined against competition from Indonesia,

South America, and East Africa (Ageely, 2008). Currently, farmers are switching to

qat cultivation as the financial returns are more lucrative. Large farmlands are now

dedicated to qat cultivation in place of sorghum and coffee (Ward and Gatter, 2000).

In Ethiopia, thousands of hectares of farmlands are devoted to qat cultivation

because of its investment value despite being a “non-nutritious and unproductive”

crop (Ageely, 2008). Qat chewing affects human productivity hence contributes little

to boost the factor. This is due to time explicitly wasted when qat chewers indulge in

their chewing sessions instead of being productive otherwise. It was suggested in

1973, that an estimated 4 billion hours or more, of work a year was lost due to qat-

chewing habit. The move to completely ban qat consumption was heavily resisted

despite heavy tax levied. The levying of high taxes on other substances such as

nicotine was able to reduce its consumption but was not effective on qat. According

to latest statistics, Ethiopians, Yemenis, and Djibouti families spent about one-third

of their income on qat consumption (Ageely, 2008).

12

1.3 Qat control in Yemen

Qat chewing habit has been rooted for hundreds of years in Yemen, both as a

social and culture-based activity. Qat is consumed to broaden social interaction and

is prominent at ceremonies such as, wedding, birth and for solace (Numan, 2012).

However, despite the scientific evidence that qat chewing has negative impact

affecting health, social and the economy, the Yemeni government has not made

serious efforts to curb qat consumption to reduce its undesirable effects (Ward and

Gatter, 2000). Prior to the unification between the south and north Yemen in 1990,

there was no law to either control qat chewing or reduce its cultivation that had risen

in popularity, particularly in the northern Yemen (Ward and Gatter, 2000).

In the southern Yemen, known as the People’s Democratic Republic of

Yemen, a law prohibited people from chewing except at the end of the week

(Thursday and Friday). Qat users to be more disciplined because of this law (Ward

and Gatter, 2000). In 1972, North Yemen prime minister banned public servants

from chewing qat during work hours including restricting its cultivation. He also

initiated a campaign using the mass media (radio, newspaper, poems, skits and

journals) to encourage the population to quit qat chewing saying it was bad for their

health. Unfortunately, the commendable efforts of the Prime Minister met with

opposition and he lost his position just after three months and the campaign he

initiated was abandoned (Ward and Gatter, 2000; Gatter, 2007).

The World Bank Report in 2007 estimated that one-third of Yemenis,

especially the rural population, depended on qat crop for their domestic income.

Restrained by this condition, the country will require a significant and balanced

policy change if qat cultivation and its usage is to be effectively controlled. At the

Yemeni International Convention in 2002, many suggestions and recommendations

13

were put forth by researchers to assist the government to fight the negative impacts

of qat (Ward and Gatter, 2000). The Yemeni government adopts a cautious policy

on its stand on qat. While imports are banned, production is legal and sales are taxed

(Ward and Gatter, 2000). Although some politicians have opposing views on qat,

there is however no concerted effort to implement anti-qat campaigns. Since 1999,

the government has adopted a number of specific policies to control, regulate and

taxes on qat. However, these policies have not successfully curbed the production or

consumption of qat. It did, however, succeed in fostering public debates on qat and

policy makers continue to seek ways to reverse the alarming spread of its usage

(Ward and Gatter, 2000).

1.3.1 Qat control in Aden (before unification)

Qat chewing was not noted among the Adeni community until the 19th

century after it was brought in from Ethiopia and Somalia. The chewing habit in the

Adeni society started in a small area around Taiz (Dhalla and Yaffa), where qat was

grown in small quantities. The governing party in Aden attempted to control qat use

among the Adenis in the 1950s. Despite this effort, there were reports of illegal use

especially among foreign Arab workers. By 1958, measures to stem out qat use had

all failed.

Following the British occupation in Aden, the People’s Democratic Republic

of South Yemen was established in 1967. The authority outlawed the chewing of qat

in Aden except on Thursday and Friday. This law was very effective in controlling

qat use among the people of Aden and in the People’s Democratic Republic of South

Yemen. In 1990, South and North Yemen unified as one country, known as it is

now, the Republic of Yemen. The new Republic replaced the old constitution and

14

abolished the previous law on qat use, though it remained valid in Southern Yemen

(Ward and Gatter, 2000). As a result, qat chewing became rampant and uncontrolled

in Aden and in many southern provinces. The government was powerless to deal

with the situation, as there was no law prohibiting the public from using qat.

However, the lack of control by the Yemeni government has enabled qat traders to

expand their business to new markets, particularly to the main cities such as Aden

and Hadramout where qat cultivation did not exists. In a World Bank 2007 report,

‘Yemen Towards Qat Demand Reduction’ the rate of qat chewing in non-cultivated

areas had reached 83% and 61% in the coastal areas and 23% in the areas around the

Wadi of Hadramout. This phenomenon gave rise to new problems in the

communities previously known to be peaceful areas (Ward and Gatter, 2000). In fact,

in some areas, qat cultivation and trading became a new source of income for the

economy.

1.3.2 Qat chewing in different cultures

In Yemen and southern Saudi Arabia, qat chewing is one of the traditional

habits within communities. Qat chewing is very common as some people believe that

it can overcome fatigue and depression and confer a euphoric effect for a more active

lifestyle. In Ethiopia, people have used this plant to treat ailments such as depression

or as part of their dietary requirements. long-distance drivers who are known to chew

qat to keep them awake and more energised and for better concentration (Al-

Motarreb et al., 2002; Baynesagne et al., 2009).

Qat chewing is endemic among Yemenis, Somalis, and other minorities in

Ethiopia and Kenya. It is not prohibited in Islam unlike alcohol where its use is

clearly stated in the Holy Quran (Verse 219 in Surah 2 and Verses 90 and 91 in

15

Surah 5, and the Hadith). However, there are disagreements on the permissibility of

qat chewing in Islam; some scholars deem it as impermissible while others (primarily

Yemenis) do not see it as such. Qat is also used by some Yemeni community and

farmers for crafts (Kennedy et al., 1983; Kalix, 1984; Krikorian, 1984; Mekasha,

1984; Weir, 1985; Hassan et al., 2007).

1.4 Qat chewing and mass media educationan campaigns in Yemen

The media play an essential role in any society. It is an undisputable fact that

media campaigns do have strong impact on the audience of different social classes

(McQuail, 1977; Straubhaar et al., 2013). Media is considered as the most important

source to publicize information and create awareness among the society. Media

campaigns are used around the world for targeted individuals and the society. Such

campaigns may focus on various issues e.g. health, agriculture and education. A

successful campaign can yield the desired results and significantly improve a

prevailing unhealthy situation. One of the most widely used media campaign is on

stamping out smoking and the use of substance of abuse (Levy and Friend, 2000).

This study on qat usage will focus on Yemeni secondary school students.

This section of the Yemeni population was chosen for two reasons: First, Yemen is a

country where student numbers is very low (Gatter, 2002). Second, students are

generally considered as the backbone of the society. Healthy students can deliver a

wealthy society and result-oriented nation. The Yemeni government does not control

or limit qat growing, production and sale. Farmers and landowners are not

encouraged to grow alternative cash crops (Ward and Gatter, 2000). There is also no

policy to control or reduce the number of chewers, especially the younger

population. Perhaps it is also the unwillingness of the people themselves to change.

16

In fact, most if not all people do not recognize that this habit has negative effects on

health, social and economic aspects of life (Ward and Gatter, 2000; Numan, 2012).

To educate people on the health risks associated with qat chewing, it is

important to design an awareness campaign that can effectively highlight the

negative and harmful effects of qat on health including its social and economic

implications. The influence of the media on society can be quite profound, be it the

good or less desirable aspect. Nevertheless, its effect on children and youth can be

quite intense (Gatter, 2002; Sacks, 2003; Gatter, 2006).

There are several ways to use the mass media to curb qat chewing. A mass

media campaign proposed in a 2002 convention to counter the negative effects of qat

use in Yemen included dissemination through radio and television, lectures,

newspapers, internet and printed materials (Abdul-Malik, 2002). However, this

process did not take place as planned (Ward and Gatter, 2000). Generally, in Yemen,

there is poor utilization of mass media channels specially to target health issues and

social matter. Instead, they are more used for other purposes such as marketing and

trading propagandas (Gatter, 2006).

Anti-qat chewing campaigns activities in Yemen are rarely publicized and it

can be said it was practically not done until the writing of this chapter. This could be

due to the lack of, or, poor planning by the government to control the cultivation,

production, sale and use of qat. Furthermore, the negative attitude of the general

population is clearly reflected by the way they live their life and the activities they

indulge in, especially among the youths (Ward and Gatter, 2000). It is therefore vital

and urgent for NGOs and other civil society in Yemen to put concerted effort to

counter the qat chewing habit and reduce the negative consequences of qat practices

on population life (Ward and Gatter, 2000). Recently, some anti-qat NGOs in Yemen

17

under the auspices of the United Nations Children's Emergency Fund (UNICEF)

have taken on this initiative but they had little political backing to fight against qat

consumption. As pointed out by Ward and Gatter (2000) such initiative requires full

governmental as well as public support for the outcome to be noticed.

This study focuses on an important section of the Yemeni population, that is,

the secondary schools students. It is the first study of its kind to examine qat chewing

among Yemeni secondary school students using the mass media as a study tool. This

section is aimed to development the mass media tool and the use of educational

program to improve the secondary school students’ knowledge, beliefs, attitudes and

behaviour on qat chewing habit in the Aden city, Yemen.

1.5 The history of educational system in Aden city

The educational system in Aden, considered as the oldest in the area, started

in 1930s, before World War II. At that time, there were about 1,000 students

enrolled in the public schools and around other 2,000 studied in private education.

Majority of the teachers in Aden then were English and Indian. In 1943, the British

Council introduced English classes for both men and women in Aden. In addition,

young people from elite backgrounds had the opportunity to attend primary and

higher education system in UK elite schools and universities.

Immediately after the independence of PDRY (South Yemen) in 1967 from

British occupation, the PDRY’s education system was expanded, nationalized, and

Arabized. In 1975, the structure of educational schooling system changed to two-

eight-four: two years of kindergarten, eight years of basic schooling (effectively

covering primary and preparatory or lower secondary), and four years of secondary

schools. The education system was completely free at all levels with students

18

(Anaam et al., 2009). Pupils were given free textbooks and transportation. In rural

areas where small villages distributed around within the same area of a governorate,

but further apart, pupils were also given free board. At the universities levels,

students were also given a monthly stipend equivalent to about half of the average

salary at that time.

The education system that was adopted in the Republic of Yemen after

unification in 1990 was essentially a blend and merger of both systems of the Yemen

Arab Republic (YAR), (North Yemen) and PDRY People’s Democratic Republic of

Yemen (South Yemen) with few changes. The current education system consists of

nine years of primary education, followed by three years at secondary level. At

recent count, public secondary schools numbers in Aden city were 35 and 14 were

private secondary schools. The student numbers stood at 181,087 in both public and

private basic education and 23,686 in the secondary school systems in the Aden city

(Ministry of Education, 2009).

1.6 Purpose of the study

1. The purpose of the study is to evaluate the current level of knowledge,

beliefs, attitudes and behaviors among public secondary school students on

qat chewing in Aden city, Yemen.

2. To develop the practical and effective intervention tools to improve students’

knowledge, beliefs, attitudes, and behaviors.

3. To evaluate the impact of intervention (using tools) on students knowledge,

beliefs, attitudes and behaviors.

4. To develop a model to improve students’ knowledge, beliefs, attitudes and

behaviors throughout Yemenis education system.

19

1.7 Rationale of the study

1. The lack of information and knowledge on qat consumption and increased the

level of qat chewing habit among Yemeni people, particularly children and

students.

2. The results of this study will be utilised to provide information to the

knowledge, beliefs, attitudes and behaviour which could be used as a basis

for the preparation of a remedial action by the relevant authorities.

3. The outcome of this study will be useful to both Ministry of Education and

Ministry of Public Health in drafting effective guidelines to reduce problems

associated with qat chewing habit among Yemenis.

4. The results will enable policy makers to create and formulate new policies to

control the cultivation and production as well the consumption of qat in

Yemen.

5. The study findings may be utilised as references to counter other possible

drug problems in Yemen.

1.8 Study hypothesis

The second grade secondary school students in Aden have less knowledge on

the harmful effects of qat chewing;

There is no relation between students' knowledge and socio-demographic

factors (pre-and post-intervention);

There is no relation between student’s beliefs and attitudes and socio-

demographic factors (pre-and post-intervention);

There is no relation between students beliefs and perception with socio-

demographic factors (pre-and post-intervention);

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There is no relation between student’s behaviour and socio-demographic

factors (pre-and post-intervention);

1.9 Study questions

1. What is the impact of the mass media educational campaign in the knowledge,

beliefs, attitudes and behaviour of secondary school students about qat

chewing habit?

2. What is the level of secondary school students’ knowledge before and after

the intervention particularly for those who were exposed to the campaign?

1.10 Study objectives

1.10.1 General objective

To evaluate the effectiveness of mass media education campaign on knowledge,

beliefs, attitudes and behavior related to the health, social and economic impacts of

qat chewing among public secondary school students (second grade student’s) in

Aden city, Yemen.

1.10.2 Specific objectives

(A) Prevalence study

1. To determine the prevalence and patterns of qat chewing among the public

secondary school students in Aden city, Yemen.

(B) Mass media education campaign study

1. To develop and validate the campaign tools on knowledge, beliefs, attitudes and

behavior on qat chewing effects among public secondary school students in Aden

city, Yemen

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2. To assess and determine the level of students’ knowledge, beliefs, attitudes and

behavior related to qat chewing effects among public secondary school students

after the final intervention in Aden city, Yemen.

3. To assess the impact of the mass media tools after the program among public

secondary school students in Aden city, Yemen

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CHAPTER II

LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK

2.1 Qat chewing prevalence

A study conducted by the National World Bank (2007) revealed the

prevalence of qat chewing in seven cities on Yemen, with age groups of 12 years and

above accounting for 54.4% of the overall figure (Gatter, 2007). Al-Khader and

Darwish (2009) reported the prevalence of qat chewing among male medical Yemeni

students in Aden showing an increase in frequency from their first to the final year of

study (35% to 90%). Qat history has played a major role in Yemeni Society culturally and

traditionally, which may explain the conflicting beliefs among Yemeni students. In the past

two decades, qat chewing habit has spread rapidly and extensively among the general

population.

There is evidence of a growing number of school children who are attaching

themselves to the usage of qat and indulging in qat chewing (Arrabyee, 2002). The

lack of knowledge on the adverse health effects of chewing qat does little to reduce

the usage (Corkery et al., 2011). Traditionally, qat chewing is only initiated when a

person turns 20 years old. These days, however, chewers start even as early as 8 to

10-years-old. This is noted in qat cultivating countries, e.g. Yemen, Ethiopia and

Kenya, (Griffiths, 1998; Alem et al., 1999; Nabuzoka and Badhadhe, 2000;

Carrier, 2005). In fact, qat consumption in these countries has become a youth

culture.

Similar to tobacco smoking, several factors may accelerate this habit, such as,

less or non-existence of anti-smoking campaigns, higher exposure to pro-tobacco

messages, normalisation of smoking (community acceptance), parents and friends

using tobacco, and, the affordability of the product. All the above-mentioned factors

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may make teenagers more inclined to smoke (Seo et al., 2008). The popularity of qat

chewing varies between population in the cultivating and producing countries such as

Yemen, Ethiopia and Kenya. Most studies are carried out in the local communities.

Some clinical studies and homogenous samples include all age groups such as

university and school students. Ageely (2009) found that the prevalence of qat

chewing among junior and high secondary school male students in southern Saudi

Arabia was 63.90% in the Jizan Province, a qat cultivating area. In Ethiopia,

(Kebede, 2002) reported that prevalence of qat chewing among students was 26.6%,

and, 10.9% indulged in smoking as well as chewing qat. Baynesagne et al. (2009)

has record that the prevalence of qat chewing among university students in Ethiopia

is 31.2%. Almost half of the qat chewers in the study used the product for relaxation

and to boost their performance.

Hannani (2004) was conducted astudy among Yemeni university students. He

has found that 81.1% male and 25.9% female students have chewed qat. Statistics

show qat chewing among this group to be approximately 2.3% (female students) and

38.2% (male students) who use the substance on a daily basis. Interestingly, the

study also found that about 19.8% of female and 35.1% of male students were not

willing to stop using qat. In another study, to measure the prevalence of qat chewing

among medical students in Aden University also involved both genders. Bawazeer

(1993) reported the number of medical students’ qat chewers as 17.2%.

In Somalia, Elmi (1983) reported that the prevalence of qat chewing among

the Somalia’s was 59%. A similar study in Kenya reveals that qat chewing

prevalence among Kenya’s Northeast population is as high as 88 % (Aden et al.,

2006). According to Litman et al. (1986) the prevalence of qat chewing in diasporas

was about 39% among Jewish immigrants, Yemenis male in Israel.

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On Europe, there were a few published studies conducted among Yemenis,

Somalis and Ethiopians refugees. However a study among Somalis in the United

Kingdom found that the prevalence of qat chewing was 24% to 67%, male and

female, respectively (Ahmed and Salib, 1998; Nabuzoka and Badhadhe, 2000;

Griffiths et al., 1997; Griffiths, 1998; Bhui et al., 2003). Gebreslassie et al. (2013)

conducted a study in Ethiopia on undergraduate students and found that the

prevalence of qat chewing, alcohol drinking and smoking was 7.9%, 32.8% and 9.3%

respectively. Comparison on the prevalence of qat chewing from several studies

conducted in Ethiopia, Kenya, Tanzania, Saudi Arabia and Yemen on school and

university students are as shown (Table 2.1).