Felt Need and Treatment-seeking Barriers among Substance Abusers in Urban Slum Area in Central India.

INTRODUCTION: Substance abuse is known public health problem in the world. Felt need of treatment and barriers in seeking treatment are important for successful treatment of addictions. Therefore, this study was designed to understand the pattern (type) of substance abuse among residents of urban slum and to study the felt need and barriers for the treatment of substance abuse among substance abusers in urban slum areas of the central India.
MATERIALS AND METHODS: A community-based cross-sectional study was conducted in slum area in central India.
RESULTS: The smokeless tobacco (92.5%) and alcohol (70.35%) were the most common substances used in the study population. More than half (60.4%) of study participants were felt the need of de-addiction but in reality very few approached for treatment for their addiction. The most common barriers were unawareness about place of availability of treatment, absence of any health problem and the confidence of handling their own drug problem, and dependency on substance.
CONCLUSIONS: There was huge gap in the felt need and actual treatment-seeking practice due to treatment barriers in the treatment of substance abuse.

INTRODUCTION

Substance abuse is known public health problem in the world. The harmful use of alcohol results in 3.3 million deaths each year. On average, every person in the world aged 15 years or older drinks 6.2 L of pure alcohol per year. Less than half the population (38.3%) actually drinks alcohol; this means that those who do drink consume on an average 17 L of pure alcohol annually. At least 15.3 million persons have drug use disorders. Injecting drug use reported in 148 countries, of which 120 report HIV infection among this population.[1]

The previous epidemiology research on substance use and addiction in India has been mostly regional, and it has been difficult to have a single inference on national prevalence.[2] The National Family Health Survey (NFHS) 3 has shown increasing trend of alcohol in male and tobacco use in Indian women as compared to previous NFHS.[3] Substance abuse is well-known phenomenon in urban slums in India.[456] The pattern of alcohol drinking has drastically changed from occasional and ritual drinkers to social event.[7]

Taking part in treatment has generally had positive outcome. To have treatment benefits, substance abuser must seek treatment options for better outcome. A large majority do not seek treatment. Studies from western world have identified few treatment barriers such as perceived absence of problem, negative social support, fear of treatment, privacy concern, and committed lifestyle are known barriers in the United States.[8910] A study conducted in the rural Punjab has identified few barriers in treatment such as time conflicts, absence of problem, fear to treatment, admission difficulty, and poor treatment availability.[11] Female substance abusers had major problem with privacy, fear to treatment, and absence of problem.[11] Understanding health-seeking behavior of substance abuser is important link in providing effective health care for treatment and prevention of complications of substance abuse.

The felt need and barriers in the treatment of substance abuse and their health-seeking behavior for treatment of substance abuse among slums residents are unexplored in central India. Therefore, this study was designed to understand the pattern (type) of substance abuse among residents of urban slum and to study felt need and barriers for treatment of substance abuse among substance abusers in urban slum areas of the central India.

MATERIALS AND METHODS

A community-based cross-sectional study was conducted in slum areas which are field practice area of Urban Health Training Centre of NKP Salve Institute of Medical Sciences, Nagpur, located 4 km away from institute. Study area mostly comprises migrant population.

Study population and study subjects

Substance users of all age groups from this slum area were the study participants for this study. Substance abuse was defined as the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.[12]

Sample size and sampling

Data were collected for period of 2 months from May 2015 to July 2015. Sample size was calculated by considering one of the barriers that is “admission difficulty” as 24% at 95% confidence limit with 5% absolute precision, so calculated sample size was 280.[11] As purpose of this study was to know treatment barriers among substance abusers, therefore, we have adopted “snowball sampling technique” to reach desired sample size.[13]

Data collection

An approval from the Institutional Ethics Committee was obtained before conduct of study. Before collecting data from respondents, a good rapport was established with them, and confidentiality was maintained. A written informed consent was taken from all the study participants. Decision of participation in the study was respected. Data were collected by interview using predesigned and pretested questionnaire. Questionnaire was prepared with contextual modification in barriers to treatment inventory (BTI)[89] and perceived felt need in the treatment of substance abuse. Information on pattern (type) of substance abuse, felt need of treatment, and barrier in treatment-seeking behavior for the treatment of substance abuse such as absence of problem, negative social report, fear of treatment, privacy concerns, time conflicts, poor treatment availability, admission difficulty, and others were noted. Polysubstance abuse was defined as the use of three or more than three substances used for a period of ≥12 months. After completing data collection from study participants, they were counseled and motivated for the treatment of substance abuse. All the treatment-seeking study participants were referred to the department of psychiatry for treatment. Confidentiality of identity of study participant was maintained.

Data analysis

Data were entered and analyzed using Epi Info software version 7.1.1.14 (Atlanta, USA). All the categorical variables were expressed in percentages with 95% confidence interval for all the variables in the study.

RESULTS

The selected sociodemographic characteristics of study participants were presented in Table 1. It reveals the most of the participants were male (92.50%) only 7.50% were females. Half of the study participants were in the age group of 31–55 years followed by 10–30 years and least in the age group of 56 years and above. There were two study participants of 12 years of age who were addicted. Most of the participants (42.14%) were educated up till higher secondary or above. Only 16% were educated up till primary classes. The majorities (45%) of the study participants were industrial labor followed by farmers which hold 22.85% of the total study population and 9.64% each were professionals and businessman. Students constituted 8.57% of the study population and 4.28% were unemployed.

Table 1

Socio-demographic characteristic of study subjects

Figure 1 shows pattern (type) of substance abuse. The smokeless tobacco (92.5%) was the most common substance used in the study population and 65.35% in the smoking form. Alcohol constituted 70.35% of the study population. There were 7.2% of the study population who were addicted to weed (Ganja is locally known as weed) and brown sugar. The prevalence of polysubstance abuse (three or more than three substances for a period of 12 months or more) was 7.5% among study participants.

Figure 1

Pattern (type) of substance abuse. *Numbers in parenthesis are number of study participant. @weed (local terminology for ganja), brown sugar. #All addiction (polysubstance abuse)

Out of total study participants, 60.4% of the study participants consider themselves as addicted to substance that they use and want to get rid of the addiction. Around 39.6% were comfortable with the addiction and want to continue with their substance abuse without thought of leaving substance abuse. Hence, more than half (60.4%) of study participants were felt the need of de-addiction but in reality very few (1.1%) approached for treatment for their addiction [Table 2].

Table 2

Perceived addiction, felt need of treatment and treatment seeking behavior

Questions regarding barriers to treatment were asked using BTI, but only 259 study participants responded to the questionnaire and rest refused to respond BTI [Table 3]. Most of them were not aware about where go for de-addiction treatment in their locality. This is the major barrier (73.57%) identified in the treatment of addiction among study participants. Other major barriers were the absence of any health problem (40.15%) and the confidence of handling their own drug problem (42.47%). The major concern shown by participants was that they cannot live without drugs (36.29%). Hence, they feel it will be difficult for them to manage friends and families, so afraid of losing friends (34.36%). Some of them told that their friends have told them not to go for a treatment (20.07%), few shown concern of failure to treatment (22.40%). Some people who they know who had a bad experience with treatment (17.3%). Some of the participants were afraid about their family will be embarrassed or ashamed if they go for a treatment (16.99%). Few were accepted drug use as the way of their life (9.66%) and few have shown no faith in a treatment by saying “I don’t think treatment will make my life better (8.88%).”

Table 3

Treatment seeking barriers

DISCUSSION

Addiction is a social and major public health problem in Indian slums.[456] Studies on pattern of substance abuse in urban area have revealed that there is high prevalence of tobacco, alcohol, and illicit drugs abuse. The most common substance used is tobacco followed by alcohol and other illicit drugs in Indian slums.[46] The similar finding was found in the present study. This study has not studied the prevalence of substance abuse among general population. It is study of the pattern (type) among substance abusers. Among substance used, we too found very high number of tobacco (smokeless and smoke) use then followed by alcohol and others such as weed (local name for bhang and marijuana) and brown sugar. The findings are worrisome for the polysubstance users (using three or more than three substances for a period of ≥12 months). The studies have reported polysubstance abuse as one of the treatment-seeking barriers among rural India.[11] Polysubstance use was found to be 7.5% in our study among substance abusers. A study conducted at drug de-addiction center Chandigarh has also shown the magnitude of polysubstance use ranging from 5.8%–13.9%.[14] There was male preponderance for the substance abusers as local culture is male dominated and mostly were migrant population for work in industrial work.

Taking part in the treatment for substance abuse may have positive outcome. Therefore, the felt need and barriers in treatment seeking are important for policy changes. Understanding treatment-seeking behavior of substance abuser is important link in providing effective health care for treatment and prevention of complications of substance abuse. The previous studies have recognized barriers for the treatment such as absence of problem, negative social support, and fear of treatment, privacy concern, and committed lifestyle are known barriers in the United States.[8910] A study conducted in the rural Punjab has identified few barriers in treatment such as time conflicts, absence of problem, fear to treatment, admission difficulty, and poor treatment availability.[11] The major barriers identified in our study are lack of awareness about where to take the treatment, then lack, or absence of health problems. The present study also found fear to treatment with various concerns about treatment such as they cannot live without drugs (36.29%). Hence, they feel it is difficult to treat and afraid of losing friends (34.36%). Some of them shared experience of the treatment of their friend which was not encouraging to them. Their friends discourage them to take treatment. There was strong belief that treatment will fail in any case (22.40%). The embarrassment and shame of family was associated with treatment. Few of them accepted their addiction as way of their life not interested in treatment. Overall, all the findings show that there were a lot of taboos and misconceptions associated with treatment-seeking behavior. The gap in knowledge of treatment and treatment-seeking behavior was substantial.

What our study adds is that this study assessed the felt need of treatment and treatment-seeking behavior. There were 60.35% of study participants who were considering themselves as addicted and want to get treated, but very few (1%) of them were consulted for treatment. None of them has approached specialist in de-addiction (psychiatrist). This indicates poor treatment-seeking behavior. There is waiting period for opting treatment even though 60.35% felt treatment should be sorted out. The waiting time for treatment of substance abuse is well known even in developed world.[10] There is immediate need for creating awareness about availability of treatment for early treatment, considering barriers in the treatment.

The knowledge of the felt need of treatment and barriers in treatment seeking in substance abusers is important for policy making and may be useful in guiding and planning program for the prevention and control of substance abuse.

As this study has not calculated the prevalence of substance abuse among general population and we have adopted snowball sampling for collecting data, whereas in other studies were not having similar methodology. It was making comparison difficult. Multiple studies on barrier to treatment and felt need of treatment in Indian context need to be conducted for clear scientific knowledge in this field.

CONCLUSION

The pattern of substance is comparable with other studies. There was substantial felt need of treatment but having very poor treatment-seeking behavior. There were many barriers identified in the study. The major barriers identified in our study are lack of awareness about where to take the treatment, then lack or absence of health problems, fear to treatment with various concerns about treatment such as they cannot live without drugs, felt difficulty in treatment, afraid of losing friends, and friends negative experience of treatment. A strong behavior change communication strategies are the urgent need for improving the treatment-seeking behavior among substance abuser.

This work was undertaken with the help of Indian Council of Medical Research (ICMR), New Delhi's Short Term Studentship (STS) program (STS ID: 2015-01198). We want to acknowledge the financial support and sponsorship given by ICMR, New Delhi for this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.