Introduction

Substance misuse is becoming a growing global health problem that has a significant impact on physical, psychological, legal aspects and overall quality of life.¹ This issue is particularly relevant to university students, as it was recently evident that student status is associated with an increased rate of substance misuse when compared to non-student peers.² The opposition of this revelation to previous findings has sparked interest in reexamining reallife data and reassessing our understanding of substance misuse, its risk factors, and its impact on individuals experiencing it.

It is believed that the social aspect of being a university student is associated with an increased tendency to misuse substances; factors include an increased sense of independence, decreased sense of parental control, and peer pressure. Furthermore, it is also believed that students may resort to misusing substances to cope with academic stress or behaviors associated with it, like sleeping problems.³ Previous results indicate that the prevalence of substance misuse among students in Jordan is noticeably higher than the general population, 17.5% vs 1.7%, respectively.^4,5

In a Middle Eastern context, multiple studies were conducted to estimate the prevalence of substance misuse among university students. In Kuwait and Egypt, the estimation of misuse was 14.4% (n= 1,587) and 6.5% (n= 1138), respectively.^6,7 Iran, Jaharoom estimated the prevalence to be 36.2% (n= 1149) among university students.⁸ In Jordan, a 2008 study was one of the very few studies that examined this issue and estimated the prevalence of substance misuse to be 17.4% (n= 835) in one university alone.⁴

The lack of regular, updated data in the Middle East and Jordan can be attributed to multiple factors, such as social stigma, the fear of social abandonment, potential trust issues, and religious beliefs.⁹ Given the current scarcity of data concerning substance misuse in Jordan, this study aims to assess substance misuse rates among students from three different institutions in Jordan and explore the potential risk factors to provide updated data for future studies and policy development.

Methodology

This is a quantitative, cross-sectional design was used in this study. The participants in this study were recruited from 3 governmental universities in Jordan: the University of Jordan, Hashemite University, and Jordan University of Science and Technology. Distribution and participation were conducted randomly in each university. Only undergraduate students from both genders were enrolled in this study, as the characteristics of the postgraduate cohort do not align with the aforementioned factors that influence substance misuse among university students.

Data collection

An online questionnaire, adapted from WHO guidelines, was titled ‘A Methodology for Students Drug Use Survey.’¹⁰ The questionnaire was adjusted to serve our study aim as follows: questions about frequency of usage and age of first use were generalized to all substance categories (sedatives, hallucinogens, and stimulants), as the purpose is to determine the prevalence regardless of the types. Questions about religion and the source of the used substances were potentially deterring and thus omitted, so were questions about the history of migration and reason for substance use for not aligning with the study’s objective. The modified questionnaire was divided into two sections: the first section was for demographic data (gender, age, college, academic year, residency, parents’ level of education, family size, and monthly income), and the second section was for substance use data that is consisted of questions about the type of substance used, frequency, age of first use and perceived repercussions. The questionnaire was translated into Arabic and handled by 25 medical students randomly selected from the University of Jordan. The final questionnaire was carried out without further modifications.

Procedure

Participants were recruited in-person and digitally from 3 universities between October and December of the 2021-2022 academic year. QR codes redirecting to the online questionnaire were distributed. Non-eligible participants were excluded automatically.

Data analysis

The collected data were analyzed using SPSS version 25.0. Means and standard deviation (SD) were calculated for the variables. Multiple regression model used to identify independent factors. To find the association between some factors and illicit drug use, we applied the Chi-square test with an Alpha of 5%, and the results will be considered significant if the calculated p-value is less than Alpha, where the p-value < 0.05.

Ethical considerations

Ethical approval was obtained from the Institutional Review Board at Jordan University Hospital, the University of Jordan (IRB – JUH). A written consent form at the beginning of the questionnaire was needed to proceed with the questionnaire and obtain verbal approval from each participant who used the QR code. A clear explanation of the study’s purpose was provided, and participation was voluntary and anonymous.

Results

A total of 1184 students participated in this study, all included. In this sample, the mean age of participants was 20.89 (s=2.347) years old, the mean number of siblings was 4.441 (s=2.0864), with the majority of participants being females, 61.6% (n=729) vs 6.3% males (n=75) (Figure 1). Most participants were from the University of Jordan, with 90% (n=1066) of the participants, followed by Jordan University of Science and Technology at 6.3% (n=75) and Hashemite University at 3.6% (n=43). Students from the faculty of medicine were the most represented in our sample, representing 31.6% (n=373) of the participants, followed by students from the faculty of Languages, representing 19.2% (n=227). The least represented faculty was the faculty of sports, representing only 0.5% (n=6) of the participants. Regarding the year of study, 27.1% (n=321) of participants were in their fourth of study, 21.7% (n=257) were in their third year of study, and 9.7% (n=115) of participants were in their sixth year of study. However, all of them were medical students in a 6-year program. For family income, 42% (n=497) of participants reported a monthly family income ≥ 1000 Jordanian Dinars (JD), with 19.8% (n=234) reporting an income between 700-1000 JD and 5.4% (n=64) reporting an income less than the latter (Table 1).

Table (2) below shows the reported lifetime prevalence of smoking, alcohol consumption, and illicit drug use with further details. The majority of participants were non-smokers, 61.7% (n=731). For Alcohol consumption, 93.8% (n=1111) reported being teetotalers, leaving only 6.2% (n=73) of participants reporting alcohol consumption. In terms of using drugs for non-medical purposes, only 18% (n=213) of participants reported participating in this behavior, while 82% (n=971) did not report it. For the frequency of using overthe- counter medications, narcotics, or abusing a prescription-only drug, the majority of participants, 72% (n=853), reported never doing so, with the remainder of the minority reporting a variable frequency of use (Table 2). Regarding the use of illicit drugs, 88.2% (n=1044) of the participants reported never using any illegal drugs, while 11.8% (n=140) reported a history of using illicit drugs, such as Marijuana and Cannabis. Interestingly, the most misused medication was benzodiazepine, with 27% of drug misusers reporting multiple-drug use (Figure 2).

Table (3) below shows the prevalence of participants reporting drug misuse within 12 months, 1 month, and 1 day before completing the questionnaire. Notably, 8.4% (n=99) of participants reported drug misuse in the last 12 months, 5.3% (n=63) reported abuse in the previous month and 2.3% (n=27) reported misuse within a day before completing the questionnaire.

In our sample, we found no significant association was found between illicit drug use and family income (p=0.195). However, a significant association between illicit drug use and smoking (cigarettes, Shisha, or e-cigarettes) was found (p<0.05).

The association was also significant between illicit drug use and alcohol consumption (p<0.05). There was a statistically significant relationship between large family size and illegal drug abuse (p-value 0.011). Illicit drug use was not associated with gender in our sample (p=0.336).

Although gender was not significantly associated with illicit drug use, our analysis indicated that male gender was significantly associated with more frequent illicit drug use (p=0.008) (Table 6).

Table (7) below shows the frequency of substance use in both genders among students, with the majority reporting yearly use of 77.1% (n=108), followed by weekly, then daily consumption, with the minority reporting a monthly use.

Discussion

In this study, the overall lifetime prevalence of substance misuse among university students was found to be 11.8% (n=140), which is slightly less than the prevalence reported in previous literature, particularly the study conducted in Jordan among Hashemite University students that quoted the prevalence to be 17.4%.⁴ However, the prevalence is higher than that of the general population, estimated by the WHO at 1.7%.⁵ Moreover, multiple studies that were done in the Middle East reported a similar lifetime prevalence of substance misuse; e.g., in Kuwait, lifetime prevalence was found to be 14.4% among male university students. 6.5% in Egypt, 12.7% in Türkiye, and 12.6% in Iran.^{6, 7, 11, 12} The reported prevalence in this study is still lower than the prevalence rates in various Western and Eastern studies. For example, in St. Petersburg, Russia, the estimated lifetime prevalence among a similar cohort was 20%, 22.2% in a similar Portuguese cohort, and 58.7% in a cohort based in the United Kingdom.^13,14 Nonetheless, the lower prevalence in our study and other Middle Eastern studies can be attributed to the social and religious stigma of substance use.⁹

The result of this study showed that sleeping drugs, including benzodiazepines, were the most misused substance at 45% (n=63), while the second most misused substance was marijuana/cannabis with 10% (n=14) prevalence. Multi-substance users account for 27.1% (n=38) of the cohort, all of whom reported using marijuana/cannabis in addition to other substances. This finding is in agreement with a study conducted among university students of Rafsanjan, Iran, which reported that benzodiazepines were the most commonly abused substance, with a 7.4% prevalence.¹⁵ On the other hand, many studies shared different results; the most used substances were cannabis/marijuana in Egypt, Kuwait, Ethiopia, Russia, and Spain.^{6, 7, 16, 13, 17}

Substance use among students is more likely to be episodic and not associated with severe health risks. However, this use pattern leads to the slow development of dependence.¹⁸ In our study of the sample that reported substance use, the monthly and daily users were 5% and 7.2%, respectively, and the yearly consumption was the commonest at 77.1%.

More than half of the participants in our sample were females, 61.6% (n=729), while males were 38.4% (n=455). We found no relationship between overall lifetime substance use prevalence and gender (p=0.336). Nonetheless, other studies have found a significant relation between male gender and overall lifetime prevalence of substance misuse, which is the case in cohorts in Egypt, Sudan, Türkiye, Iran, and Nepal.^{6, 19, 11, 20, 21} Despite the statistical insignificance relating gender status to the overall lifetime prevalence of substance use, we found a significant relationship between the male gender and increased frequency of substance use (p=0.008). This result is congruent with numerous studies in Northern Ireland, Wales, England, the City of Jahrom, Southern Iran, and Lebanon.^{8, 18, 22}

Furthermore, we found a positive relationship between large family size and illegal substance use (p=0.011). Notably, being a part of larger families is not unknown in the region, so the relationship between the illicit usage of substances and large family size could be an unfit measure of significance. More than one-third (n=507) of the sample have reported a family size of ≥ 5 members. Substance misuse was significantly associated (p<0.05) with alcohol consumption and smoking in all its types: cigarettes, e-cigarettes, and Shisha, aligning with the published data of Northern Ireland, Wales, England, Eastern Türkiye, Sudan, Egypt, Spain and Iran.^{17, 19, 22, 23, 24, 25} This significant relationship between illicit substance use with tobacco smoking and alcohol consumption could be explained by the Gateway Hypothesis, which refers to the pattern of substance misuse whereby legal substances such as tobacco and alcohol precede the use of such substances, including marijuana/cannabis, cocaine, heroin, and other drugs.²⁶ Several retrospective and longitudinal studies reported a positive association between early tobacco smoking and alcohol consumption and later consumption of marijuana, cocaine, and other illegal, more addictive substances.^{27, 28, 29, 30}

The sample size was one of this study’s limitations, as it would be advantageous to increase the number of participants for a better representation, particularly from the other universities.

Moreover, the sample was taken from only three governmental universities, with the majority from the University of Jordan. In comparison, there are 27 universities between the public and private sectors. By factoring in the societal and religious stigma, combined with the fear of legal prosecution, we believe the prevalence of substance misuse is underestimated, hence why a larger sample size to overcome this dilution is warranted.

Conclusion

Substance misuse among university students was high compared to the general population’s prevalence, with a reasonable assumption that it is underestimated due to social and religious beliefs.9 Substance misuse was significantly associated with alcohol consumption and all types of smoking (p<0.05). This up-to-date data on substance misuse and identified factors associated with it is potentially informative for further studies and useful to establish awareness campaigns that aim to enhance health status and the ultimate quality of life among young adults.

Declaration

No conflict of interest to declare.

This article was not funded by any external organization.

This article went through IRB processing to ensure confidentiality and quality standards were met (8413/10 2022) at University of Jordan.