Bridging the gap: a study on substance use among the adolescents in a rural area of Jaipur

Study area

The Department of Community Medicine at the National Institute of Medical Sciences and Research, Jaipur, Rajasthan, considers the Rural Health Training Center in Achrol as one of its field practice areas. Achrol, situated in Amber Tehsil in Jaipur District of Rajasthan, is just 7.5 km away from the National Institute of Medical Sciences and Research, Jaipur, Rajasthan. Prior to conducting the study in Achrol, necessary permission was obtained after providing a detailed explanation of the study’s intent and research methodology.

Study population

This was a cross-sectional study done in the rural area Achrol of Jaipur. Inclusion criteria were adolescents residing in study areas for at least one or more than one year. Excluded from the study were adolescents undergoing extended medical, psychiatric, or chronic illness treatment and those whose parents did not provide consent. The data was collected between December 2023 and May 2024 over a one-year period.

Sample size

Research conducted by Dobhal P et al. [13] revealed that 15.8 % of adolescents were found to be using substances. Using the formula 4PQ/L2 with a prevalence of substance use at 15.8 % and an absolute error of 5, the calculated sample size is 419. Accounting for a 10 % loss to follow up, the required sample size to be covered in schools is 461. As a result, we surveyed 461 adolescents in the rural area Achrol of Jaipur.

Sampling method: systematic random sampling

Sampling frame was taken from already existing socio-demographic data from the study area. According to the data, there were 2,800 households in Achrol area. Dividing the total no. of houses with the calculated sample size, i.e. 2,800/461, we get an interval of 6. Therefore, the first house was chosen randomly from the houses numbered 1–6. Thereafter, every 6th household was chosen starting with the first one. Then, one adolescent from that household (10–19 years) was selected by simple random sampling technique. The house(s) were visited one day prior to the interview, to take permission and appropriate time from the head of the household for the participation of the adolescent of their family and the interview was done accordingly. If an individual who was selected by the above process is not available for the purpose of the study on making three consecutive visits, then the next participant was selected using simple random sampling technique. This process was followed till the completion of our sample size.

Study tools

The study utilized a pre-developed and tested semi-structured questionnaire based on the WHO steps questionnaire, which underwent certain modifications. A pre-test of the questionnaire was conducted in October 2023, involving 50 adolescents from a different rural area within Jaipur city. Following the pre-test results, the questionnaire was appropriately adjusted. Waist circumference of each student was measured by positioning the tape at the midpoint between the last palpable rib and the top of the hip bone at the end of expiration, with subjects standing upright in a relaxed stance, ensuring the tape was wrapped over the same spot on the opposite side. The measurements were then compared based on the percentile for the specific age group and sex [14]. All subjects had their weight measured using standard electronic weighing machines, which were placed on a flat surface. Height was measured in centimeters without any footwear, using a stadiometer. Participants were asked to stand straight, facing forward, with their heels, buttocks, and back touching the scale vertically. Height was recorded to the nearest 0.01 m [15]. Prior to conducting the survey, the research significance was communicated to the participants. A preplanned, pre-validated, partially structured questionnaire was completed with detailed explanations provided for each question to the participants. Participants were motivated to respond to all aspects of the questionnaire to ensure no questions were left unanswered. Subsequently, physical measurements such as height, weight, and waist circumference were documented.

Definitions used in the study

Household is defined as a person or group of persons who commonly live together and take meals from a common kitchen unless exigencies prevent them from doing so. According to the WHO growth charts, having a BMI less than 2 standard deviations below the WHO growth standard median is classified as underweight. Similarly, having a BMI greater than 1 standard deviation above the WHO growth standard median is categorized as overweight, and having a BMI greater than 2 standard deviations above the WHO growth standard median is considered obese [16]. We define someone as physically inactive if they do not engage in three or more days of vigorous-intensity activity for at least 20 min per day, or five or more days of moderate-intensity activity or walking for at least 30 min per day, or five or more days of any combination of walking, moderate, or vigorous intensity activities totaling at least 600 min per week [16].

Ethical issues

Parents of the adolescents were provided with detailed information and their written consent was obtained and the assent was taken from the study participantsThe confidentiality of all collected information was maintained.

Statistical analysis

The information was inputted into a main spreadsheet using MS Excel and subsequently moved from MS Excel to SPSS Software version 21.0 for analysis. Questionnaire was checked for completeness and correctness before entering into the worksheet. Regular intervals were used to perform data validation checks for the data inputted into the MS Excel worksheet. A random question was selected and verified after every 10 questionnaires were entered. After data entry of every 25 questionnaires, two random questionnaires were selected and an independent person verified the data entered. Simple tables and cross tables were made. Appropriate diagrams were made to illustrate the results e.g. Bar Diagrams, Pie Charts. For qualitative data analysis Chi-square test was used.

Socio demographic profile of the study participants

The age group of study subjects was between 11 and 19 years with maximum 246 (53.3 %) study subjects were in the age group 14–16 years. In a similar study conducted Dhobal P et al. [13], the maximum (67.5 %) participants were also in the same age group 13–16 years. Other similar studies conducted by Mohan B et al. [17] and Ramachandran et al. [18] took the same adolescent age group respectively. In the present study the mean age of study participants was 14.1 ± 1.2. In another study by Kokiwar PR et al. [19], the mean age of study participants was found to be 15.03 ± 3.0. In the present study, males were more (69.6 %) as compared to females (30.3 %). Dhobal P et al. [13] conducted a similar study in which males (58.8 %) were also more than females (41.2 %). In another similar study conducted by Jasani PK et al. [20], it was found that equal numbers of males and females were there in the study. The reason for this difference may be due to the difference in sampling strategy. The lower middle group comprised 40.7 % (i.e. about two-fifth) of the study participants as per the modified B.G Prasad Socioeconomic scale, with the upper middle group consisting of 27.7 %. Only (4.7 %) were in the poor group. In a similar study conducted Dhobal P et al. [13], it was found that almost the same (41.1 %) percentage of study participants belonged to the lower middle class. Sharma Aet al. [12] discovered that the majority of rural adolescents come from lower socio-economic backgrounds.

Prevalence of substance use

The overall prevalence of substance use was 26.4 % among our study participants which was less as compared to multicentric study conducted by U Venkatesh et al. [21] in 2024, in which higher (32.8 %) overall prevalence of substance use was reported. In our study, among the study participants, about one tenth (13.4 %) had consumed alcohol in the past and only (8.8 %) had consumed alcohol in the past one month. About three fourth (77.6 %) of study participants had never consumed alcohol. Beer was the most commonly consumed alcoholic drink. In another similar study by Jamia B et al. [22], it was discovered that among adolescents about 28.2 % had consumed alcohol (ever) at some point, and only 1.7 % had drunk alcohol once a week in the previous 6 months. Similarly in a study conducted by Kumari D et al. [23], only (6.1 %) students ever used alcohol. This difference among prevalence of alcohol intake across various studies may be due to differences in cultural factors and study area. Among the participants of our study, one tenth (10.4 %) of them had smoked in the past and only (5.2 %) had smoked in the past month. Only (2.1 %) were daily smokers. Majority 389 (84.3 %) of study participants had never smoked in the past. Cigarettes and bidi were most commonly smoked tobacco products. A study with a similar approach was carried out by Kumar et al. [24] in which they found prevalence of ever smoking and current smoking as 16.4 and 10.2 % respectively. Narain R et al. [25] found that (2.2 %) were exclusive smokers. Among our study participants, only 32 (6.9 %) had consumed smokeless tobacco in the past and only 20 (4.3 %) had consumed alcohol in the past month. Majority 409 (88.7 %) of the study participants had never consumed any type of smokeless tobacco products. Khaini and gutka were the most common forms consumed. In a similar study by Kamate et al. [26] in slums of south India, it was found that about three fourth (78.7 %) of adolescents were consuming smokeless tobacco. A study with a similar approach was carried out by Kumar et al. [24] in which they discovered that the prevalence of ever and current tobacco chewing as 13.1 and 9.4 % respectively. Narain R et al. [25] found current tobacco chewing by (4.1 %) students. This difference among prevalence of alcohol intake across various studies may be due to differences in cultural factors and study area. In the present study, only 12 (2.6 %) had consumed Intravenous drugs in the past and only 7 (1.5 %) had consumed Intravenous drugs in the past month. Majority 442 (95.8 %) of the study participants had never consumed any type of Intravenous drug. In a study conducted by Kugbey N et al. [27] among adolescents in Sub-Saharan countries of Africa, it was also found that only (2.6 %) of participants were consuming drugs. Also only (4.2 %) of participants had consumed illegal drugs in a study conducted by Jamatia B et al. [22] in tripura adolescents. Higher prevalence of drug use was found among adolescents of the USA in a study conducted by Volkow N et al. [28]. The reason for higher prevalence in this study may be due to difference in study settings and different socio economic status.

Associated factors for substance use

Among the participants of the present study, the majority (69.8 %) of them had normal BMI, while only (8.4 %) and (5.2 %) were overweight and obese respectively. In a study carried out by, comparable findings were documented by Singh SK et al. [29] among rural adolescents in which it was found that the majority (70.5 %) had normal BMI while only (8.1 %) and (5.3 %) were overweight and obese respectively. Raj M et al. [30] did a study in which they discovered that the prevalence of overweight children rose from 4.94 to 6.75 % between 2003 and 2005. Other similar studies by Sharma A et al. [12] found that 22 % were overweight and 6 % were obese. Rani MA et al. [31] found in a similar study that 5.2 % were found to be obese and 6.2 % overweight. In our study participants, more than half 270 (58.5 %) of them were doing high levels of physical activity (running, cycling, cricket, football, walking), while only 33 (7.1 %) were doing low levels of physical activity. Rani MA et al. [31] found similar results that 15.6 % were inactive, 43.4 % were minimally active, and the remaining 41.0 % belonged to the category of health enhancing physical activity. Among the study participants of our study, more than half 268 (58.1 %) of them were non-vegetarian and about two fifth 193 (41.8 %) of them were vegetarian. Among the study participants in the present study, almost half 214 (46.4 %) of them were consuming 3–4 servings and one third 153 (33.1 %) were consuming five or more than five servings of fruits and vegetables. In a similar study in rural adolescents by Singh SK et al. [29] in Delhi, it was found that more than half (58.3 %) study participants were Non vegetarian and about half (55.5 %) of them were consuming 3–4 servings and about one fourth (27.1 %) of them were consuming five or more than five servings of fruits and vegetables.

Association of substance use with associated risk factors

In the present study, it was observed that late adolescent age had significantly (p<0.001) higher proportion of consumption of intravenous drugs. All other forms of substance use that is alcohol, smoking and smokeless tobacco had no statistically significant correlation with age difference among adolescents. In a similar study conducted by Jhakar A et al. [32] also reported that higher prevalence of substance use was found in late adolescent age. Similar findings were reported by others where they observed that with the increase in the age prevalence of substance use also increased amongst street children [10], 11]. The difference might be because our study only involved adolescents, whereas their study included both pre-adolescents and adolescents. In the present study, it was observed that males had significantly (p<0.001) higher proportion of alcohol and smokeless tobacco consumption as compared to females. All other forms of substance use that is smoking and intravenous drug use had no statistically significant association with gender among adolescents. In a similar study conducted by Daniel LT et al. [33], it was also found that nearly more than half (55.6 %) of the male adolescents reported to use one or more substances in their lifetime. Higher prevalence of substance use among males as compared to females was also reported in studies conducted by Jasani P et al. [20] and Dobhal P et al. [13] in Jaipur. Presence of family history of Substance use had significantly (p<0.001) higher proportion of alcohol and smoking consumption as compared to females in the present study. All other forms of substance use that is smokeless tobacco and intravenous drug use had no statistically significant association with family history of Substance use among adolescents. Jhakar A et al. [32] and Ganguly S et al. [34] also reported a higher prevalence of substance use among those who had a positive family history of any substance use. Obesity had significantly associated with (p<0.001) higher proportion of alcohol, smoking and smokeless tobacco consumption while underweight was significantly associated with (p<0.001) higher proportion of intravenous drug consumption in our study. Dobhal P et al. [13] in Jaipur conducted a similar study in Jaipur which found that the prevalence of tobacco use was notably higher among underweight individuals compared to those who were obese. Upon examining various forms of substance use in relation to levels of physical activity, it was noted that lower levels of physical activity were significantly associated (p<0.001) with a higher proportion of all forms of substance use, including alcohol, smoking, smokeless tobacco, and intravenous drug consumption. This suggests that adolescents who engage in substance use are likely to be less involved in sports and physical activity due to various health concerns when compared to their peers who do not use substances.

Our study demonstrated strength through the high response rate of participants. We thoroughly examined the well-known risk factors for substance use among the participants and implemented specific inclusion criteria to prevent selection bias. Our study adhered to standardized guidelines and procedures for anthropometric measurements and data collection. We also pre-tested the questionnaire in a different area before using a modified version, which further strengthened our study. However, a limitation of our study was that measurements were conducted by a single observer. Additionally, we did not consider factors such as living environment, psychological stress, and detailed nutritional assessment. Furthermore, our study’s results may not be generalizable to the entire adolescent population, as it was conducted solely in adolescents from a rural area in Jaipur. We also acknowledge that the use of a self-report questionnaire may have introduced under-reporting or over-reporting. It is possible that focus group discussions or one-to-one interactions could have provided a more comprehensive understanding of substance use and associated risk factors in the study population.