Prevalence of betel or areca nut (AN) use and its associated factors among Bhutanese population aged 15-69 years old : an analysis of national health data of non-communicable disease (NCD) survey in 2019
Authors:   , Penjor Tashi 
Published: September 2023

Background: Although betel or areca nut use has less global attention and public health concern than smoked tobacco uses, but it is particularly one of a neglected public health problem in Bhutan in which the masticatory use of betel is rampant and epidemic. Its use is also directly infused in Bhutanese tradition and social fabric. There are currently no policies that specifically target the regulation and consumption of areca nut use and trade in Bhutan, while it is classified as carcinogenic to human by the WHO (International Agency for Research on Cancer, IARC) in 2004. Series of national surveys have consistently shown high prevalence of betel or areca nut use in Bhutan. The National Health Survey (NHS) of Bhutan 2021, found that 43.9 percent of Bhutanese aged 15-75 years old used areca nut in the form of betel quid. In 2016,  the Global School–based Student Health Survey (GSHS) assessed the prevalence of areca nut use amongst students aged 13-17 years old at 65.8 percent with 48.9 percent chewing betel quid. Furthermore, the Global Youth Tobacco Survey (GYTS), Bhutan on 2019 indicated that 56.9 percent of adolescent students aged 13-15 years consumed betel nut or various product containing it. Likewise, the WHO STEPS 2019 reported prevalence of areca nut users at 56.8 percent amongst 15-69 years old. However, analytical studies pertaining to the factors associated with this high prevalence using the latest data were significantly rare and not updated. The objective of the study is to assess the prevalence of betel or areca nut use and its associated socio-demographic, personal behavioural and individual health status in recently year.

Methods: This is an analytical cross-sectional study. The secondary data collected in a nationally representative Non-communicable Disease Risk Factor Surveillance WHO STEPS Survey 2019 of Bhutan conducted among Bhutanese aged 15-69 years old. The survey included a total of 5575 participants; selected through a multistage stratified cluster sampling. The outcome variable of interest is current betel or areca nut use. Weighted analysis was done to calculate the prevalence of betel or areca nut use, personal behavioural measurements, and individual health status. Univariate and multiple logistic regression were performed to identify correlates for betel or areca nut use and to estimate the unadjusted and adjusted odd ratios.  

Results: The prevalence (weighted) of current betel or areca nut use was 56.82 % (95% CI: 54.27-59.33) of Bhutanese aged 15-69 population. Significantly higher prevalence of 63.58 % (95 % CI: 60.58 - 66.48] were found in the age group 25-39 years. Tobacco users are 17% more likely to use betel nut as compared to those who don't consume tobacco (aOR 1.17, p=.0001) Similarly, former alcohol consumers were 12% and current alcohol consumers were 45% more likely to consume betel nuts as compared to lifetime abstainers.  Associated factors to betel or areca nut use i.e age, alcohol use and tobacco use were found.

Conclusion: The findings indicate that more than half of the Bhutanese population consume betel or areca nut. Young and middle-aged individuals, Alcohol users and tobacco users should be targeted with public health initiatives and behavioural interventions. Including, a multisectoral approach to regulating areca nut trade and commerce should be initiated while also forming measures to national control betel or areca nut use.