Reducing Khat use among Somalis living in Kenya: a controlled pilot study on the modified ASSIST-linked brief intervention delivered in the community

The chewing of khat leaves (catha edulis) is a Janus-faced practice typical of several countries around the Horn of Africa: although traditionally used for centuries among certain ethnic groups, its consumption is undergoing great changes, and it is now the main substance of abuse in several of these countries, with misuse being increasingly practiced [1, 2]. The preferred means of consumption is chewing the fresh leaves and tender stems with the effects of excitability, euphoria, talkativeness and flow of ideas. Technical progress, such as in transport infrastructure, have enabled khat production and its availability to increase significantly. Today, the khat sector is a considerable part of the national economies of Yemen, Ethiopia and Kenya, where the substance is legally traded and consumed [3, 4].

In contrast to the traditional moderate method of consumption, modern excessive patterns of use are related to various physiological and psychological health consequences [5‐12]. While researchers recognized the potential of khat to induce psychological dependence early on, recent studies have confirmed this, showing the high dependence potential and high dependence rates in several populations [13‐17].

Despite the great need for culturally adapted medical and psychological interventions for khat misuse and dependence, there is currently very limited knowledge available on this specific topic [2]. In one single study, psycho-education had a small effect on khat use behavior among psychotic patients in Somalia [15]. Because most countries in which khat use is common have an understaffed and over-burdened public health system, with little or no institutional care for addiction [18], most suitable interventions would be those which involve little resources and can be implemented by community health workers or in primary care settings, such as screening and brief interventions (SBI). There is strong evidence for the effectiveness of SBI in primary healthcare settings in reducing hazardous alcohol use [19]; however, the evidence for other substances is weaker [20, 21]. No specific study to date has targeted khat use interventions, and no such study has ever been conducted in community settings.

Somalia is among the world’s ‘Fragile States’ [22] and has continuously suffered from organized violence, famine and natural disasters over the last decades. By the end of 2014, more than 1.1 million Somalis were internally displaced and 970,000 were living as refugees in neighboring countries. Kenya has a strong ethnic Somali minority; additionally, more than 420,000 Somali refugees were hosted by Kenya by the end of 2014 [23]. Because of the culture of khat use, it is very likely for Somalis to chew khat to cope with adversities; it is supposed to strengthen a sense of identity and social wellbeing [24, 25]. After traumatic experiences, the amount of use was shown to be increased in order to reduce painful memories and cope with other symptoms [26]. In previous studies, extreme khat misuse patterns were found among the Somali refugee population in Kenya as well as a great need for prevention and intervention tools [16]. The World Health Organization’s (WHO) recommendation to include substance use prevention and intervention into the general healthcare [27] is problematic for urban Somali refugees in Kenya who do frequently not access healthcare services when severely ill [28]; one explanation why they avoid utilization of government-run healthcare is the missing residence permit and the associated threat of deportation [29]. Thus, alternative approaches to deliver khat-related prevention and intervention tools outside healthcare facilities are needed.

Here, we report on a pilot study that had two aims: (1) We wanted to gain initial experiences on the acceptance and applicability of interventions to reduce khat consumption in Somali culture where its use is an integral part of the contemporary life style and where at the same time misuse is increasing. We also aimed to pilot test the feasibility of the delivery of khat-related interventions in community settings because in this region healthcare settings are overburdened with already existing tasks and not frequently utilized by the target group. By that we wanted to explore new ways of reaching disadvantaged khat user groups. (2) Secondly, we wanted to generate initial data on the effectiveness of a khat version of the ASSIST-linked brief intervention (BI) that had been adapted to Somali language and culture among a non-treatment-seeking and a non-selected community sample of khat chewers. We expected that khat users from the community would reduce their khat use after receiving ASSIST-BI when compared to a control group who only participated in the repeated assessments of their substance use. We expected small reductions in the amount and frequency of khat consumption in favor of the treatment group.

161 participants were assigned to the SBI and 169 to the AC group. Table 1 reports the socio-demographic and socio-economic data of both groups. They were comparable in relation to all items.

The duration of the ASSIST screening and brief intervention for the intervention group was 28.8 (±12.5) minutes at t1 and 13.1 (±8.0) minutes at t2 (refresher); in the AC group, the intervention at t3 took 38.5 (±14.9) minutes.

The experiences during study implementation showed an unexpected positive reception in the khat-using community: the study team easily recruited 330 participants out of 366 approached khat users, who motivated friends also to participate, clearly showing that counseling support to reduce khat use was greatly sought after. The dropout rates in both groups were small and comparable, supporting the high acceptance of a khat-related SBI in the target population (see Fig. 2). The feasibility of the intervention was high, as our local team had no difficulty to perform it in the Somali culture.

The present study demonstrated the feasibility and provided preliminary data on the effectiveness of a khat-specific screening and brief intervention in male Somali with limited access to public healthcare from a community in Eastleigh/Nairobi.

Male Somali khat chewers from the community in Eastleigh/Nairobi participated in a khat-specific screening and brief intervention study (one session of modified ASSIST-linked brief intervention plus refresher vs. assessment only) with a 2-month follow-up. Due to pre-existing group differences, we partially matched the groups for statistical testing. Screening and brief intervention for khat use was well accepted and could be easily applied in Somali culture, as shown by this study’s ability to recruit and retain participants as well as through the application of the FRAMES model during training and study without any difficulties. It was evident that today, the wish to reduce one’s own khat use is clearly present in the Somali community in Nairobi. This matches with several recent studies from Ethiopia that found approximately 70% of khat chewers had the intention to stop khat chewing [43]. These results support the idea that focusing on khat users in community settings to deliver SBI for khat is a feasible approach to reach disadvantaged groups who do not utilize government-run healthcare. The main empirical findings of this study were that khat use amount and frequency were reduced in the intervention group vs. assessment-only control in the first month, but no differences were found in the second month; due to methodological problems, this result needs to be considered preliminary evidence for the effectiveness of SBI for khat. This result shows, however, the positive potential of very brief psychotherapeutic interventions, even if conducted by trained laypersons, in non-medical settings and with non-treatment-seeking participants from the community in the Somali khat culture, in which khat is integral part of daily life. These results encourage to conduct further research on the SBI approach because there isn’t any controlled empirical research on khat use interventions and observational studies show the difficulties to maintain abstinence without professional support [44].

In this study, we dealt with a form of substance use that is strongly related to a defined geographical region, specific ethnic groups and cultures, and which has a longstanding tradition and use culture as well as numerous social functions [45]. It is likely that members of the Somali community in Nairobi use khat to strengthen group identity and to cope with various stressors and psychopathology [5, 24‐26, 46, 47]. It is almost impossible for male Somalis to participate in social life without chewing khat: their physical and social environments are full of khat-related triggers and role models aggravated by the lack of alternative leisure activities. It is equally likely that members of the Somali community use khat to cope with past and current adversities, such as those related to every-days experiences of discrimination and the illegal immigration status. This background is important when discussing intervention effects. Nevertheless, khat misuse patterns develop swiftly in this group, causing a lot of harm, and prevention and intervention concepts are urgently needed. Our pilot study shows that there is potential to develop feasible and effective concepts for prevention and intervention that require little resources and can be implemented sustainably in the community without adding another task to the already over-burdened healthcare system.

In the reported study, the preliminary effects of SBI on khat use were small; that is, at the end of the observation period the intervention group had reduced the amount by more than 10 khat bundles more (absolute change calculated from unmatched observed data; baseline range 8 to 336 bundles in 28 days; AC mean 48.11 (±43.91), SBI mean 58.56 (±48.11)) and the frequency by more than two days more (absolute change calculated from unmatched observed data; baseline range 4 to 28 days; AC mean 20.74 (±6.28), SBI mean 21.57 (±6.40)) than the control group. These differences are indeed small, and only reached significance for use frequency. When compared to previous studies, especially in non-western settings, larger effect sizes were reported [35]. These small effects can be explained by some typical features of khat use and by some characteristics of our study: compared to conventional intervention studies, we set the inclusion criteria very low and aimed for a representative community sample instead of a treatment-seeking sample. As a consequence, we included users with a wide range of consumption patterns, from addictive and excessive use to moderate and occasional use. Most other SBI studies pre-selected participants and included only those with moderate use, recruited from primary care facilities and with probably higher levels of motivation to change. Because of these factors, we had to deal with large variances in our two central outcome measures (amount and frequency), which made it difficult to identify small changes by methods of statistical testing. The variance of our measures of amount of khat use is large, especially because of the local definition of a standard unit: a relatively small quantity that easily varies at the individual level between one and ten per day. Additionally, we employed measures to retain participants in our study—even those with minimal motivation to change—such as methods to minimize the effort for participants to keep the follow-up appointments by, for example, setting very flexible times and locations, and we had two staff members from the community to motivate participants. This led to very low dropout rates, and even participants with low interest and motivation completed the study, which of course weakened the effects. Furthermore, the unselected community sample presented another problem: comorbidity with other mental disorders. In another publication on these data [48], we showed a very high prevalence of depressive, posttraumatic and psychotic symptoms in this sample, and that co-morbidity decreased the effects of SBI. Here, we were not focusing on comorbidity and did not control for it. Still, we found preliminary evidence for a reduction in khat use by SBI in the whole sample.

Additionally, we have to take into account a variety of factors that might have diminished the difference between the intervention and control conditions: First, the control group also showed intervention-like effects, as revealed by the course of change (Fig. 3). Especially in the first month, earlier reduction occurred in the SBI group, and the control group partially caught up in the second month. The overall reduction in khat use might have various reasons: The assessment of khat use and related problems (e.g., comorbid psychopathology) could have worked as intervention-like elements, comparable to the balancing exercise of MI. All these assessment components can create discrepancy and change talk. In other studies, control groups have also shown a reduction in their substance use [49]. Another reason for the small difference between intervention and control conditions might have been the counselors: trained young college graduates are not trained health workers, for whom the ASSIST-linked BI was originally developed. They had probably not performed the intervention as effective and might have not managed to deliver the difference between the two arms—treatment fidelity—as experienced health staff.

But in sum, preliminary effect size measures showed the expected small treatment effects (Cohen’s d = .29 and d = .13) favoring SBI, and we believe that the aforementioned factors all increased the external validity of the study and show the potential of SBI to reduce khat use in the community.

This study also needs to be discussed in the context of the growing evidence that SBI works for alcohol, but that its effectiveness for illegal substances is seriously questioned [21]. Richard Saitz [21] discussed potential explaining factors, such as non-legal status or comorbid use of other substances among drug users. In the Somali community in Nairobi, khat use has some features that are typical for alcohol use in western countries: khat is a fully legal substance; it is normal to use khat, and chewing is even considered part of the mainstream Somali culture; and in contrast to other substances, moderate Islamic currents sanction khat use. Though we found relatively low comorbid substance use, in contrast to representative samples [50], khat use in Eastleigh has also some similarities to illegal drug use in Western countries, such as the amphetamine-like effects and the typical use culture. Thus, khat chewing cannot be easily classified along the distinction between alcohol and illegal substances in western countries.

Based on our experiences from this and other projects with Somalis, we conclude that psychotherapeutic measures can be culturally accepted and applicable among this extremely disadvantaged population and in the difficult setting of the countries around the Horn of Africa and delivered in community settings instead of the already overburdened primary healthcare centers. These results provide initial support for the applicability and effectiveness of an economical prevention and intervention that requires little investment in time and training. It might have a great potential to change khat use on a broader scale. It is justifiable to allocate further resources to the development, evaluation and implementation of khat treatment and prevention programs. There is great demand for such programs in the traditional khat-using countries, in which these are completely lacking.