Prevalence and predictors of recreational drug use among medical and nursing students in Cameroon: a cross sectional analysis

Medical and nursing students in Cameroon are likely to have mental health problems given the stressful nature of their studies. Paucity of mental health institutions in the country implies they hardly get access to professional help when needed and are obliged to develop coping strategies such as recreational drug use. This study aims to determine the prevalence and predictors of recreational drug use among a group of Cameroonian medical and nursing students. Cross-sectional analysis of 852 medical and nursing students (mean age 21.78 ± 3.14, 31.49% males) recruited by convenience sampling from three state-owned medical schools; and from two state-owned and two private nursing schools in Cameroon over a four-month period (January–April 2018). Information was collected via a printed self-administered and structured questionnaire from consenting students. Multivariable logistic regression analysis was used to identify independent predictors of recreational drug use. The overall prevalence of recreational drug use was 1.64% with tramadol and marijuana noted as the drugs used by these students. Independent predictors of recreational drug use were: presence of a chronic illness (OR 5.26; 95% CI 1.32, 20.97; p = 0.019), alcohol consumption (OR 5.08; 95% CI 1.54, 16.73; p = 0.008) and Total Oldenburg Burnout Inventory score (OR 1.11; 95% CI 1.02, 1.21; p = 0.021). The use of recreational drugs by medical and nursing students in Cameroon remains worrisome despite its very low prevalence, as it may negatively impact their performance and health.


Introduction
Recreational drugs are legal and illegal drugs used without medical supervision. The four categories of recreational drugs include analgesics, depressants, stimulants, and hallucinogens [1]. The increasing use of recreational drugs among students has become a rising and disturbing phenomenon worldwide [2,3].
This uprising problem is relevant in Cameroon. A rapid assessment on drug abuse in Cameroon carried out in 1996, reported that males and females of all age groups were involved in the consumption of recreational drugs [3]. According to the report, narcotics consumed in Cameroon ranged from Cannabis (Marijuana) which was the most consumed, to traditional drugs, a host of other pharmaceutical drugs, as well as cocaine and heroin [3].
Consumption of marijuana and other stupefying drugs has been reported amongst medical and nursing students elsewhere [4]. The prevalence of recreational drug use among students in the health sector generally ranges from 2% to as high as 64% [5][6][7][8]. The reasons for which students consume recreational drugs include pleasure and relaxation, peer influence, cigarette smoking, and heavy drinking [9,10].
Medical and nursing students have been shown to have high rates of mental health disorders such as burnout, stress, anxiety and depression [11][12][13][14]. Several reports suggest that stressed and depressed students, tend to use Open Access BMC Research Notes *Correspondence: tsinjim@gmail.com 3 Health and Human Development Research Network, Douala, Cameroon Full list of author information is available at the end of the article alcohol and other recreational drugs more often as a coping strategy [15,16].
There is dearth of data regarding recreational drug use in Cameroon as a whole, and among students of the health care sector in particular. In order to bridge this gap, we set out to determine the prevalence and predictors of recreational drug use in a group of medical and nursing students from state-owned and private medical and nursing institutions in the country.

Study population
Study participants included 413 medical students from three randomly selected medical schools (University of Bamenda, University of Douala and University of Buea and 447 nursing students from the two-state owned (University of Bamenda and University of Buea) and two private nursing institutions (Saint Veronica higher institute of biomedical and nursing sciences Buea and Saint Louis higher institute of health Bamenda). Participants were recruited for the purpose of a greater project aimed at assessing burnout and depression among medical and nursing students in Cameroon and some of the methods have been published in a previous project [17]. A total of 860 medical and nursing students were recruited by a convenience approach.

Study design and protocol
This was a cross-sectional analysis carried out over a period of 4 months (January 2018-April 2018) using medical and nursing students recruited from the abovementioned institutions. Students were approached and the nature and purpose of the study explained to them individually. Students who agreed to participate in the study signed a written consent form, and were then handed a printed, structured questionnaire (in English or French depending on their language preferences) to fill and return at their earliest convenience.

Study instrument
The study instrument was a printed structured questionnaire made up of three sections. The first section (Additional files 1, 2) sought the following socio-demographic characteristics: age; sex; marital status; presence and number of (children) dependents; level of studies; number of hours spent studying; presence of problems in personal relationships (defined as a close connection between two people formed by emotional and sexual interactions); monthly income and the perception of sustainability on their monthly income; average academic results attained; alcohol use; recreational drug use and type; smoking and history of any chronic disease.
The second section assessed burnout syndrome using the Oldenburg Burnout Inventory (OLBI), consisting of 16 positively and negatively framed questions which assesses two key components of burnout: exhaustion (intense physical, affective and cognitive strain) and disengagement (characterized as cynicism referring to distancing from one's work in general) [18]; with eight questions for each parameter. We used the version of the OLBI questionnaire adapted for use in an academic milieu by Reis et al. [19].
The third section assessed depression using the simple yet accurate Patient Health Questionnaire-9 (PHQ-9) [20]. Validated versions of both the OLBI and PHQ-9 in French [21,22], were pre-tested before use amongst participants with a French orientation.

Data management and statistical analysis
Data from returned questionnaires was entered into EPI Info version 7 (CDC, Atlanta) and later exported to the Stata software package version 12 (Statacorp, College Station, TX, USA) for statistical analysis.
Both subscales of the OLBI (emotional exhaustion and cynicism) were added to obtain a total score for burnout syndrome, after negatively phrased questions were reversed (1 = 4, 2 = 3, 3 = 2, 4 = 1) such that higher scores indicated higher exhaustion and disengagement in the students.
Results were presented as counts (percentages), mean and standard deviation (SD).
Univariable analysis was performed to determine predictors of recreational drug use. Variables significant on univariable analysis were inputted into a multivariable logistic regression model to determine independent predictors of recreational drug use. Significance was set at 5%.

General characteristics
Of the 860 students who filled the questionnaire, 852 provided an answer to the question on recreational drug use (99.07% response rate) and were used for the final analysis. Participants had a mean age of 21.78 ± 3.14 years (range 16-50 years), and were predominantly female (68.51%). Most of the students (70.45%) were from the state-owned universities and a majority were single (93.25%) ( Table 1). The mean total OLBI score was 37.58 ± 5.37 while the mean total PHQ-9 score was 6.92 ± 4.32 ( Table 2).

Prevalence of recreational drug use
Fourteen students admitted to using recreational drugs (Tramadol and marijuana) giving a prevalence of 1.64% (95% CI 0.98-2.74%).

Discussion
Our results indicate a prevalence of recreational drug use of 1.64% in a combination of nursing and medical students, and identified the presence of a chronic illness, alcohol consumption and burnout syndrome assessed using the total OLBI score as independent predictors of recreational drug use among this population (Additional file 5). Data on recreational drug use in Cameroon is sparse. However, there have been reports on the increasing use and abuse of the analgesic and opioid drug, tramadol, by youths in the North west region of the country, with the primary aim of trying to achieve mood and performance enhancement [23]. Marijuana alongside a large range of pharmaceutical drugs remain the most abused substances by youths in Cameroon according to certain reports [3]. This was reflected in our findings, with tramadol and marijuana being the only recreational drugs listed by participants who confirmed taking recreational drugs.
We obtained a prevalence of recreational drug use among nursing/medical students of 1.64%. The prevalence recorded in our study was considerably lower than that reported elsewhere [5,6,8,24]. This could be attributable to under reporting as recreational drug use is considered a taboo in this conservative society. Also, the Kübler-Ross model (known as the five stages of grief ) could be applicable in drug addiction treatment [25]. As such, the first phase recreational drug users or abusers go through in an attempt to come to terms with their addiction problem is denial. It is probable that only a few students using recreational drugs were past the denial phase and felt confident enough to report on the questionnaire.
Medical and nursing studies in Cameroon are quite stressful and time consuming, with students having to attend several hours of lectures daily. In addition, students are faced with the psychological and emotional challenge that comes with seeing and caring for critically ill and dying patients during internships. Dealing with the challenges that come along with managing a chronic disease alongside the stress from studies could be quite an uphill task. It is therefore not surprising that students faced with such a double dose of burden seek for a coping strategy, one of which is the use of recreational drugs [15,16]. This is worsened by the fact that mental health institutions and professionals are scarce in our setting, making it difficult for those students who recognise their need for professional help to get one. Recreational drug use could also worsen the course of the ongoing chronic illness, and negatively influence adherence to treatment [25,26]. The end result is a student who finds themselves in a downward spiral in which stress resulting from the challenges of studies and managing a chronic illness drives them into drug use, drug use worsens their disease and or compliance to their treatment and ultimately their health, poor health translates into poor performance which may lead to more stress and further drug use. Alcohol intake has been previously associated to recreational drug use and abuse, with certain studies indicating that individuals reporting frequent alcohol intake are about five times more likely to use recreational drugs [9,10]. Alcohol is regarded as a gateway drug. According to the gateway theory, the use of a psychoactive or addictive drug increases the likelihood of using other drugs [27]. Translating this in the context of our study, the intake of alcohol (a well-known addictive substance) increases the chances of use and/ or abuse of other addictive drugs such as marijuana or tramadol. Some of the mechanisms put forth to explain this theory include; the possible biological alterations in the brain due to the earlier drug which increases the chances of trying out another drug, and the similarity in the personalities of users of different drugs which makes more likely for the user of one drug to readily use another drug [28]. The association that could possibly exist between alcohol intake and recreational drug use is even more highlighted in a special population like medical/nursing students, where mental health problems exist at high levels [11][12][13][14]. Students faced with mental health problems often use alcohol intake as a coping strategy [15,16]. Alcohol intake as shown in our results, predisposes them to recreational drug use. This highlights the need for early detection of students at risk and the proper management of those already using, reiterating the need for equipped mental health facilities and properly trained mental health personnel in our health training institutions.
Burnout syndrome is relatively common among students in the health care sector [11,14]. Entrance exams into the state-owned medical and nursing schools in Cameroon are usually very competitive with limited spots available for grasp. Those who do not make it are left no other option but fight for a spot in the remaining private institutions whose tuition fees are considerably higher. Those who make it could easily get overwhelmed from the challenges involved in adapting to life in the university, adapting to the relatively new concept of the basic sciences, as well as the demanding, stressful and time-consuming nature of medical or nursing studies as a whole as stated above. All these, alongside the realization of the tremendous workload that awaits them upon completion, could readily culminate to burnout.
There is an overall paucity in the number of mental health facilities and properly trained mental health personnel in Cameroon. Consequently, special populations like medical/nursing students at risk of mental health problems such as burnout do not have access to adequate professional help and care when need arises. This further exposes them to various coping strategies, some of which (recreational drug use) may be inappropriate and detrimental to their health and performance. This highlights the need for more attention on the mental health status of students in health training facilities, in order to provide help for recreational drug users and to screen for and manage mental health problems detected early-on in this at risk population.

Conclusion
Though the prevalence of recreational drug use among medical and nursing students in Cameroon is relatively low, their use remains worrisome as it could be detrimental to both their health and performance. Predictors herein require further investigation in order to ease early identification and management of students at higher risk of recreational drug use, and to provide data needed for the reform of certain mental health policies in Cameroon.

Limitations
The cross-sectional nature of this study made it difficult to determine temporal associations between predictors such as alcohol intake, burnout syndrome and recreational drug use. We therefore cannot ascertain the direction of these relationships. We therefore recommend prospective studies to better and properly assess this relationship. Also, the frequency of drug use by participants was not assessed in this study. More comprehensive studies are required to further confirm the results of this study and assess the scale of this problem in this population. Given the sensitive nature of the topic in a highly conservative society and the fact that