A phenomenological study of families with drug-using children living in the society.

BACKGROUND AND OBJECTIVES: Adolescents have a risk of drug abuse during their development, which demands care by the parents in a family environment. This study explored the experiences of families with drug-using children.
MATERIALS AND METHODS: This study used a descriptive phenomenological qualitative design. Seven participants were recruited for the study using the snowballing sampling technique. The data collection instruments employed included interviews, field notes, and tape recorders. Sociodemographic data were collected comprising age, sex, religion, and relationships with other drug users. Interview guidelines were prepared based on the research objectives and they were further translated into a number of questions to explore the experiences of the families. Data were obtained using in-depth interviews. The Colaizzi method was used for data analysis.
RESULTS: The results characterized the feelings of the parents/families, stigma felt by families, coping mechanisms used by families, family burden, ways of fixing the problem, obtaining the support of family, and family expectations of the parties involved. The families experienced a deep, prolonged, and repetitive grieving process.
CONCLUSIONS: This study identified several themes in the experiences of families with drug-using children. We suggest that drug service agencies assign a public health nurse to act as a counselor and advocate to help families manage and overcome their problems.

Introduction

Adolescence is one of the most critical stages in a person's development [1]. During this phase, adolescents change physically, psychologically [2], and socially [3], especially in terms of their self-perception and expectations of adolescent social life [4]. They may experiment with many risky behaviors that can be adopted as lifestyle patterns [5], such as drug abuse. Drug abuse has become a global problem and it is endemic in nearly all of the countries. This is reflected by a report from the United Nations Drugs Control Program (UNDCP), which provided insights into the global extent of the use of psychoactive substances, including drugs. It is estimated that 2 billion people are alcohol users, 1.3 billion people are smokers, and 185 million people are drug users. The World Drug Report confirmed that 208 million people, or about 4.9% of the world's population, were using drugs in 2008, and in almost all countries [6].

Drug networks have also grown in terms of the level of abuse and increase in production, sales, and distribution. One cause of this rampant drug use is the existence of the Golden Triangle comprising Thailand, Myanmar, and Laos as producers of opium, which affects drug abuse in other countries [6]. Well-organized national and international criminals who move quickly are another cause, including in Indonesia [7]. Data from the United Nations Office for Drugs and Crimes (2004) indicate that drug abuse in Indonesia affects 3.2 million people, equivalent to 1.5% of the population, where the composition is 79% men and 21% women [6], [8]. According to these data, students are the most vulnerable drug abuse group. Similarly, research by the University of Indonesia and Center for BNN in 2008 showed that the increase in drug use among the adolescent population and students was about 1.99% each year. Therefore in 2008, the estimated number of drug abusers was 3.3 million, which increased to 4.5 million people in 2013. The prevalence of drug abuse at the population level will increase by approximately 28% in the next 5 years [9], [10].

The Columbia Encyclopedia (2008) states that drug abuse damages the lives and morals of young people, and it is harmful to the drug abusers themselves and the people around them. Banks and Waller (1983, in Hawari 2001 [9]) confirmed that drug abuse can lead to medical complications such as breathing problems, pulmonary edema, and liver problems, where some cases end with death. Syarief (2008) also stated that drug abuse can lead to deviant behavior in society, as well as triggering major problems that have negative effects on the functions of organs [9]. This opinion was reinforced by Martono (2006) who stated that excessive, irregular, and prolonged drug use leads to physical health, mental, and social problems [9]. According to Joewana (2005), drug abuse can interfere with work and social functioning [9]. In children, their immature development [1] may mean that this situation is not supported by adequate knowledge, attitudes, and skills to support a healthy lifestyle [11]. Therefore, the frequency of drug abuse is often greater during adolescence.

Drug abuse has a variety of psychosocial and economic impacts on the lives of families. The psychosocial impacts include sadness, embarrassment, disappointment, anger, and even despair. The future is not clear for drug users because they may become dropouts or unemployed after being expelled from school or work. Many cases occur in families that consider drug use a family disgrace, which should not be disclosed to others in order to maintain the family's honor. The family atmosphere may be comfortable and family life is disrupted. The economic impact on the family can incur enormous finance costs to fund drug use as well as drug treatment, which is expensive and takes a long time. The family may also lose their possessions if they are stolen by drug users to fund their drug needs [6], [7].

The complex problems caused by drug abuse for families with drug-using children range among psycho-social problems, economic issues, and even stigmatization and discrimination, thereby resulting in a reduced quality of life. This condition requires social support from various parties, including public health nurses (PHNs). PHNs are health professionals who have important roles and responsibilities for helping the community address the issue of drug abuse. PHNs may adopt a family approach so they require an understanding of the meaning and significance of families with drug-using children by constructing a holistic picture of the phenomena experienced based on the views of the family. The experiences of families with drug-using children need to be explored based on in-depth interviews to capture their life experiences. These experiences can only be determined in qualitative studies. Therefore, the aim of the present study was to explore the experiences of families with drug-using children.

Materials and methods

Study design

This qualitative study used the phenomenological method to explore the depth and complexity of the experiences of families with drug-using children. Experience is individualized because human nature is unique, so the experiences of families with drug-using children may differ.

This qualitative study used descriptive phenomenology as described by Spiegelberg [12]. In phenomenology, Husserl stressed that three identification processes need to be conducted to understand a phenomenon: (1) bracketing, (2) examining the phenomenon, and (3) examining the essence of the phenomenon. Phase bracketing occurs during the research process where it aims to help researchers understand the phenomenon. Spiegelberg [12] also identified three stages when performing descriptive phenomenology: intuiting (pondering), analyzing, and describing (describing the phenomenon).

Participants

Seven participants were recruited for this study using the snowballing sampling technique. In general, the number of samples used in qualitative research ranges between six and 10 people, but if data saturation is not achieved, the number of samples can be increased until saturation is obtained [13]. The participants in this study were families with drug-using children who met the following inclusion criteria: families (parents) with (former) drug-using children who were not married and lived in the central city X, who lived in one house, cared for and had direct experience of events at the time when the children used drugs, understood and were able to communicate using the Indonesian language, and were willing to participate in the study, as shown by the provision of signed informed consent. This study received ethical approval from the Faculty of Nursing, University of Indonesia.

Instruments

In phenomenological qualitative research, the researchers themselves are the means of data collection [13]. This is because the researchers explore the issues in depth to obtain comprehensive information, so the role of the researchers is as a tool to obtain information. Other data collection tools used to support the collection of data in this study comprised interviews, field notes, and tape recorders.

The data collection instruments employed included interviews, field notes, and tape recorders. The sociodemographic data collected comprised the age, sex, and religion of the subjects and their relationship with the drug users. Interview guidelines were prepared based on the research objectives, which were also translated into a number of questions to explore the experienced of the family. Interview guidelines were used for conducting in-depth interviews with the participants. Field notes were used to record the non-verbal responses of the participants during the interviews. We directly documented all of the non-verbal responses made by the participants during the interviews. Tape recorders were used to record all of the information obtained during the interviews. In qualitative research, the information obtained is not in the form of numbers and qualitative researchers use data retrieval tools instead, such as a tape recorder.

The interview questions used six guideline items based on a literature review. The six questions were: 1) what was the experience of the family when family members engaged in drug abuse? 2) tell me how you (father/mother) felt at that time; 3) (to the father/mother) please tell me about the saddest events associated with the use of drugs by children; 4) what was the father/mother doing at that time? 5) what did the father/mother want or expect at that time? and 6) what changes were experienced by the family over time when family members were still using drugs. The field notes were collected based on observations made during the interviews involving the researchers and participants, including descriptions of the responses made by participants in the pre-interaction, interaction, and termination phases.

Procedure

The data were collected during in-depth interviews based on open-ended questions for 2 months. In the orientation stage, the researchers tried to enquire about the general health condition of the participants in order to identify their readiness to participate in the interviews. The researchers created a comfortable atmosphere and maintained the privacy of the participants by conducting the interviews in a closed room. The researchers prepared a tape recorder to record the conversation during the interview and stationery to record the non-verbal language of the participants. The researchers also identified an appropriate position for the tape recorder in order to clearly record all of the conversations during the interview. The researchers conducted the interviews close to the participants (approximately 50–100 cm) to ensure that the tape recorder could clearly record the conversation. The tape recorder was placed in the open at a distance of approximately 30–50 cm from the participants.

The researchers started the interviews by giving the following question to the participants: “What was the experience of your family when your children were using drugs?” This core question was used to obtain general impressions from the participants. Some participants found it difficult to understand this question. Furthermore, the researchers used an interview guide comprising six questions including open questions to elaborate on the core questions. The interview guide contained special questions based on the research objectives. The researchers provided a general description associated with the core question. If the participants could not understand the questions, the researcher outlined the core questions in accordance with the interview guide. The researchers tried not to pass judgment based on their understanding or experience when answers were given by the participants. The interview process in this study was terminated when the necessary information was obtained according to the research objectives based on the saturation of data.

The researchers wrote field notes containing important details related to the research objectives in order to complete the interview so they did not forget helpful elements of the natural data obtained during the interviews. The field notes documented the atmosphere, facial expressions, behavior, and non-verbal responses of the participants during the interviews. The field notes were compiled to describe the responses of the participants. The field notes were written during the interviews and coupled with the transcripts. The interviews were terminated after all of the questions were answered by the participants. The researchers closed the interviews by thanking the participants for their participation and cooperation during the interviews. The researchers then engaged with the participants in the next meeting to validate the data.

Data analysis

The characteristics of the participants were analyzed using descriptive statistics. After collecting the data, the recordings of the participants were transcribed and both researchers (R. and T.S.) analyzed the transcript by reading and identifying the key words related to this study. A thematic analysis procedure was used to identify the experiences and meanings of the views in each participant's transcript [14]. In the phenomenology approach, the meaning of a participant's life experience comprises the key thematic points in the findings [15].

The data analysis process employed in this study followed the steps described by Colaizzi (1978) [16], as follows. (1) We described the life experiences of the participants by compiling a literature survey of the theory and research related to the experiences of families with drug-using children. (2) We compiled an overview of the experiences of living with drug-using children based on in-depth interviews with the participants and the field notes. (3) We read the transcripts of the interviews to obtain an overall view of the life experiences of families with drug-using children. (4) We read the transcripts to select significant statements that were meaningful for our research purposes. (5) We articulated the meanings of any significant statements by choosing keywords, before categorizing the statements made by the participants. (6) We then grouped the statements into themed groups in a table, which included a breakdown of the categories into sub-themes and themes. (7) We wrote in-depth descriptions. (8) We validated the findings based on feedback from the 10 participants.

The data analysis yielded a textual description and a structural description of the narrative or story about the events as objects that could be studied. The qualitative research information was presented in the form of a text or picture format of a life experience. The textual descriptions used in this qualitative study included: (1) using the categories mentioned by each participant, (2) the transcript of the interview, (3) using the statements that varied among participant, (4) a narrative or story, and (5) establishing keywords based on the interpretations of the researchers and participants [13].

Results

The participants in this study were four fathers (P1, P3, P4, and P7) and three mothers (P2, P5, and P6). The ages of the participants ranged between 40 and 50 years. The educational level of the participants ranged from senior high school to bachelor's degree.

The data analysis generated seven themes (Table 1). These themes were: 1) feelings of parents or families; 2) stigma felt by family; 3) family coping mechanisms used; 4) load experienced by the family; 5) how to solve the problem; 6) support provided by the family; and 7) family expectations of the parties concerned. The feelings identified by the parents or families varied widely, e.g., they did not believe, did not accept, expressed disappointment, felt embarrassment, felt shock, felt anger, felt regret, felt deep sadness, and even felt despair for their children who became drug users.

Table 1

Themes identified based on the experiences of families with drug-using children.

Significant Statements	Cathegorized	Themes
“… oh My God, first I could not believe this good boy, not according to do any problem in his life…” (P2)	Do not believe	Feelings of parents / family
“… But, a friend's apartment in say if my son loves to use ..,, I do not believe with my childs’ friends .. so I asked her don’t do anything to admit so I believe” (P6)
First, I can not believe this kid smart, stay in school and fro, moved - moved within half a year until the school moved four times in succession - succession, Do not know her child was yes,, fall drug user.. until also termed the “injector ”.. that’s a big problems …” (P7)
“… I'm still not received, this disgrace the family … my father and my mother a hajj so people look at my family respectable” (P2)	Do not accept
“… O God, already father hajj, the pilgrimage of his mother, his son why is this? …” (P1)	Disappointed
“… oh I am very disappointed, oh God why my child like this, the work already paid, become a student in university, working with his father, but suddenly become a user …”(P4)
“… 5 years in Bandung college only a year, even become a good student in university, but she suddenly a user guns, I upset …” (P5)
“… Disappointed really Nurse … very, very disappointed….yeach.. already can not anyway, in says can not rule can be for the future …” (P7)
“… Because the hajj of my father, my mother hajj also. So I keep this problem ,, I also educate these children, shame .. !! take treatment that until I was frankly embarrassed .. ”(P2)	Shame
“… Yes,,, I,, shame so … have a girl use nookie …” (P6)
“… Yes I am ashamed wong first father RW …” (P4)
“… After we're tired, dah pegel, shame, all-out …” (P7)
“… Oh … it seems already dispointed my mind already proverbial disease so that one already pleng … already hovering, I think this float are gone …” (P1)	Shock
“… I went up my child again injector with his friends. uh nutmeg headache, so dark, weak of foot O God, O God, headache … ”(P4)
“… Friend, what would you want to die ?? alright…” (P1)	Anger
“… O God … my God.. I up once then interrupted to say: (the man passable fast to dead than alive) …” (P2)
“… His father ever talk like this, Lets to write mom, lets to write it. As soon as, the police will take it, also imprisoned, eh real father died 10 days in jail you know that, which is still there so … ”(P3)
“… I never talk time to his little brother died the same like this for surviving brother, Why you not just die, already you… you…. torturing me why not just die …” (P3
You want to live what would you like to die (P.4)
“… I went up the attic Pas, e kid I've lay down near the cabinets, the needle is still insert it, I cried - cried wrote. dispointed tom y father, till want to hit him …. after we was told, I was too excited too upset … ”(P5)
“… I was so dispointed her .. already dead you only, but he wants to live? …” (P6)
“… Until that makes me upset to hit, his mother crying to take my hands …” (P7)
“… Why my child who touches” (P1)	Regret family
“… Try that at that time the big brother not rush - rush little brother mating may not like this …” (P3)
“… Try that at that time in eradicating sure my son not gonna like this …” (P7)
“… Yes, how … behind sad, tears already decomposed not known. ”(P1)	Deep sorrow
“.. I am Out gracefully, but in my heart cry, if guns shame I changed it. I cry … .If him again “a user…” (P2)
“… Yeah right, sad, sad not to play me, lost a husband not so sad. But if being a child like this Ouch my mind … ”(P3)
“… It may be in the trash, again crowd and flies, fitting coincidence my goal, but my child say…. I do not know, my child have not been over there, usually the purchasing together, this ga together, I crying, was really crying,” ( P3)
“… Sad clay if he use that, sadly did not have the heart I wrote just crying so on …” (P5)
“…. the name of difficult child was told, would I yes … what to do anymore ?? !! .. dah upset, exhausted my patience.” (P6)	Dissappointed
“.. First Expectations of parents in vain, his future is clear there is not …” (P7)
“… The neighbors say“ are you die ”. Because I see my neighborhood, so there are said a bad thing the dead … ”(P2)	Attitude and outlook Society	The perceived stigma
“… But I RW pack, never talk to person to loose and told my son.“ The gangster's wife who told told me ”…” (P3)
“… My family say you already dead, he said …” (P6)
“… Because if people who still lay, yes of course baseball can educate a child until the child is exposed to drugs …” (P2)	View yourself
“… Feel low self esteem ourselves, I think we do not have a price …” (P3)
“… If my child through, or I them on whispering or talking about me behind my child dies or say something but I said never mind…” (P3)	Social discrimination
“… The Son of our female neighbor very like also, her family definitely agree it, maybe because our children so much and his sister injector well, …” (P5)
“… It's nice meals with his father working in bank, Fired from his worked…” (P4)
“… I fall shouted, thrown dishes …” (P2)	Physic burden	The burden felt by families
“… Often wanted to kill me, often kicked, again my prayers …” (P3)
“… This principle is often torturing me ni is big, I want to be killed, strangled, often kicked, another silent prayer I wrote …” (P3)
“… Tired child feels to take care it, because it needs must we take it …” (P5)
“… Try that she seized surely burned alive …” (P2)	Psychologic burden
“… Yes thinking about it, kept his name a child is so, we are so it would not hear the sound of quiet especially if the phone, I immediately the police take him so fear of death …” (P5)
“… Until Then there are people who say, (his mother still be read qur’an here and there, but in fact her son like that) …” (P7)
“… Nearly a drug epidemic just be water, one bottle is 50 thousand, once take 500 thousand for three days, during 3 months of control … not to mention the treatment to gus m. 6-month package of 10 million … ”(P1)	Economic burden
“… I so so.. long time gradually every day injector, injector, injector, continued .. I sell all are gone, already loose, which house loose, originals. Loose all vehicles. That kid right there loosing and loosing more and then to continues … ”(P4)
“… He's every day tuh tuh both 500k, 500k mba, kept asking … I have to pay 1.8 million imprisoned there, every month food allowance 500k, yet take money, it's no money to take 25 thousand one person. My son told ntar telephone 500k money enter into the rice when visit, basically every month around 1 million … ”(P3)
“… I'm all out for treatment him, during treatment is expensive and longer time to heal …” (P5)
“… After all ,, not known for his money runs out caring he was treated back and finished goods until back to home…. all of money has loose to care it….anyway !!! …” (P7)
“… I'm so caring yourself, do not ever get - togethers with anyone …” (P4)	Social burden
“… If I'm still looking for my son, I love doing dikatakain neighbor woman had wandered night-night …” (P3)
“… Everything I were to finish with my the widow widowed 10 years ago …” (P2)	Decision-making	Problem solving
“… To solve together, who finished with his father would carry around so …” (P4)
“… Solving together with family his father to solve it, his brother was also there …” (P5)
“… Everything old brother sailing financier, if that finish with the father if the anthers - treatment anther where is me …” (P1)	The division of responsibilities
“… All the affairs of my in-law is a doctor who helped me out of the household to treatment …” (P2)
“… This child's religion is less powerful, less so the believing faith must be strong first let me recover …” (P1)	Cure
“… My son had first united with God. If you want to recover. After that depend is Allah, this has God, if you want the download please download but she's ready … ”(P2)
“… I can not anger his friends, because if my son had faith like automatic …” (P3)
“… Communication with others shy away, just want to communicate with me only (mother) so yes I was patient – kindness, slowly - slowly …” (P2)
“… I asked - well, slowly, cared for - the rightness…” (P4)
“… I softly- slowly, I said, be patient …” (P5)
“… Until the guards, whose task sometimes to buy cigarettes because I ask my son, please be watch him…” (P2)	Seeking help
“… My son never nie already a long time since we guns were able to continue once the make, injecting but he had been drinking lepso the drug dog was then both lay down, I am given tau kept me screaming for help, people came my son in cooperation immediately taken to hospital PI … ”(P3)
“… Just his father minumin same coconut water washed in the bathroom …” (P1)	Using alternative medicine
“… If people like shower by water, coconut water to drink but if I never …” (P3)
“… He said if discharged so yes shower by water and coconut water to drink so no …” (P4)
“… Ever I showering continue minumin coconut water, said - people - people …” (P5)
“… Put into boarding school Probolinggo one year, but they do not stand back to Jakarta …” (P2)	Modifying the environment
“… I take treatment alternatives to Serang massaged and given water prayers …” (P4)
“… I take the same treatment my doctor in T …” (P2)	Access health facilities
“… I take it to any where, ask people what, to follow, P cared how many times, every day wear long infusion up to many - months …” (P4)
“… To the doctor, to the DH, a week to go home, to the doctor twice a week TA outpatient treatment, I finally moved back to the hospital CM …” (P5)
“… I bring to the hospital. PI, T … ”(P3)
“… I often brought to RSCM …” (P1)
“… I tried to take it back to S it .. There is still nothing to wear so,, the invite- all of friend and friend was taken to RS.B In-patient days. He rebelled return … ”(P6)
“… I bring to this fact, to Dr. P in the alley over there just that .. yes .. in love discourses wrote .. given a drug treatment, but the child his name like that, feeling terrible … ”(P7)
“… Thank God unlike his brothers younger siblings to support substantially all of all of you to be healthy …” (P1)	Moral support	Support is obtained family
“… Yes my kids about it wrote on the lifting of the house wrote …” (P4)
“… Who aids, only my Doctor-in-law ..” (P2)
“… Fortunately, the child - my child all my help it, accompany me basically everything helping…” (P3)
“… My son had the will also followed, I follow want anything …” (P7)	Financal support
“… I wrote a rich family alone would not help at all. All the cost of living comes from my in-law, including for respected the 'A' … ”(P2)
“… Yes benefited from his father's office, first cooperation in banks’ father …” (P4)
“… Grateful that no treatment from the government that the red syrup pay Rp 10,000, - each there …” (P3)
“… There are still counseling so in the villages and in the office of RW but rarely …” (P5)	Informational support
“… like there anyway out of village, district but did not get to the bottom layer …” (P2)
“… The old man had not less - less, she wear new shoes in buying with brother and his friends that …” (P1)
“… I never complained to ade me, it's my upbringing for mistaken …” (P2)
“… I am thankful my son all the help, on together - together, but most of brothers oldest.” (P3	Social support
“… There is a good neighbor there are guns …” (P1)
“… Neighbors are also in good, if she is drunk says. “The A try again for drunk …” (P2)
“.. Neighbors some help hell there must be hell for sure, but many are ignorant indifference …” (P3)
“… No whereas the former East RW father here …” (P4)	Expectation of family	The family hopes to party - related parties
“… That would have been so already, now we have to, you need to be cured must spirit …” (P1)
“… I wish to help or kept sillient or blame so …” (P4)
“… Kept sillient, please help it…” (P5)
“… Had to go hand in hand …” (P2)	Expectation of community
“… Do not let anyone rich my child, I wrote enough …” (P4)
“… principally origin may his little brothers do not follow behavior …” (P6)
“… Do not make the added heat, especially to search it are not - do not tell strangled …” (P3)
“… come to his people who take drugs mediocre attitude wong he was not a robber, not a killer …” (P2)
“… When in contact with this children,, not to despair, not to understand that we really care for him …” (P1	Expectations of apparatus
“… The neighbors can see after my son hit, term already in contact with our neighbors now ama drug me well, wants do so …” (P3)
“… Do not be talking about, do not hide it…” (P4)
“… That the area of the edges of the times, it's mostly there, the recommendation for wards and district-taxable taxable to take it…” (P1)
“… Quick take to do not wait for the victim first and then act …” (P2)	Expectations of healthcare
“… Security-rich environment of what RW so should eh tuh young children embraced moved, instead we RW these children died of drug that's so cool her young son. Now too rich ordinary so … ”(P3)
“… More how so bold, to take it to community office …” (P4)
“… There is a direct extension so, if there are quick report, again gathering weve recommended so but to down nothing…” (P1)	Expectations of health services
“… Nothing helping from anyone, just indifferent. Nothing from community, neighbor, and primary health care, just from family … ”(P6)
“… Officers do not be rude, period of time in the AL exhausted doctor said wearing loe, disposable tattoo again why not going to die …” (P3)

Negative views by society meant that some of the participants in this study received unfair treatment, reflected in theme 2, i.e., negative attitudes and views of the community, views of the self and social discrimination, and the coping mechanism used by families to address problems. The support that families received was assigned to several sub-themes, including moral, spiritual, financial, informational, family, and social support, which were correlated with family expectations of their extended family, neighborhoods, community, and health services.

Discussion

The families in this study experienced a wide variety of feelings when their children first used/abused drugs, e.g., they did not believe, did not accept, and felt disappointed, embarrassed, shocked, angry, regretful, sad, and even despairing. These feelings appeared to be a response of the families when they denied the problems that emerged. The results of this study agree with the findings of Martocchio (1985), who proposed the related concept of mourning [9], [17]. The results associated with the feelings of the participants reflect Kubler-Ross's (1969) concept of mourning, which is divided into five stages of denial, anger, bargaining, depression, and acceptance [17], [18]. However, there is a difference between the two. Kubler-Ross (1969) incorporated anger and depression as separate phases in the process of grieving [18]. Anger is characterized as anger by individuals or families and the people around them.

The negative views of society meant that some of the participants in this study received unfair treatment, as indicated by the level-two theme regarding negative attitudes and the views of the community, as well as their views of self and social discrimination. The results support the concept proposed by Jones (1984), who suggested that stigma is due to an unreasonable public appraisal of behavior or character. This is also supported by Purwanto (2006), who explained that stigma is a negative characteristic or label given to a person or group [19]. Furthermore, Utami (2005) showed that children involved in drug abuse in the community are viewed as a consequence of the parents' failure to educate their children or be a good parent [9], [20], [21].

Coping mechanisms were employed by families to address problems with drug-using children. We found that the mechanisms employed for solving these problems involved diverting the sadness of drug users, spiritual enhancement, acceptance of facts, covering, dodging, and sacrifice. These results are consistent with the concept proposed by Lazarus (2000) who stated that coping can focus on the emotions or focus on the issue [22]. Coping by focusing on the problem aims to make immediate changes in the environment so that the situation can be resolved more effectively, as an active coping strategy. These behaviors attempt to overcome emotions, such as avoiding, blaming themselves, and organizing or releasing the emotions caused by stressors (Scott 2000) [8], [9], [14].

The results of this study suggest that the physical burden felt by families with drug-using children was associated with physical fatigue due to the parents responsibility for looking after their children. However, the parents also received harsh treatment from their children, where the children shouted at them, threw things, kicked out or even tried to kill them when their demands were not fulfilled. This eventually led to physical exhaustion in other family members, especially the elderly. As shown by Hawari (2009), physical exhaustion is experienced by parents who care for drug-using children and the elderly [18], [20], [23].

Due to the long-term treatment period, high costs, and the need to provide funds for drugs, the families also carried a high economic burden. Families with drug-using children also required funds or fees for other needs, and they often had to sell their belongings. More money must be spent to resolve this economic burden. The psychological burden felt included feelings of worrying about being arrested or killed. These findings are consistent with the results of a survey conducted by the BNN (2008) [6], [9], [24].

Some participants in this study experienced social impacts due to the presence of drug-using children, such as indifference and restricted activities in the environment. The social impacts determined in this study had similar characteristics to the theoretical concept of loads according to the WHO (2000) [25]. We identified the following themes related to overcoming this problem: decision making, allocation of responsibility, modifying the environment, and access to health facilities. These themes agreed with the concept proposed by Friedman (2003) who suggested that the family structure comprises four interrelated aspects: structure, roles, family power structure, system of values within the family, and the communication process [26].

We also identified the different types of support for families with drug-using children: moral, spiritual, financial, informational, family, and social support. The forms of support identified in this study agreed with the findings of Bart (1994) [26]. Support for families is highly beneficial for drug users because families no longer feel that they are facing the problem alone. The results of this study support the concept proposed by Friedman (2003) who suggested that families perform the functions of coping with affective issues and providing emotional comfort, as well as assisting with shaping and maintaining the stress [27].

In this study, families with drug-using children expected emotional and financial support from family members. The emotional support came in the form of attention, affection, and acceptance from all family members. The financial support was in the form of the funding needed for medical expenses. These findings agree with those of Friedman (2002) who proposed that the family affective function provides comfort for family members by helping family members form and maintain their identify when stress occurs in family [26].

The people in this study expected the family to provide support when family members were drug users and treat them as part of the community. Families with drug-using children also expected support from the community in the form of public acceptance and a proactive attitude toward combating drugs in their area so families with drug-using children could live normally. The families expected all parties involved to address the drug problem. They also expected support from the authorities in the form of a firm and proactive stance regarding combating drug trafficking. Some participants hoped that drug dealers would be punished to deter traffickers. The families expected support from health personnel and facilities in the nearest health centers or service units. They had expectations related to the proactive attitude of health workers when delivering health promotion efforts and treatments related to drug use, including comprehensively improving services at all levels of society. The families in this study also expected the clinics to be responsive and proactive with respect to all of the problems faced by families with drug-using children.

This study identified several themes among the experiences of families with drug-using children. In particular, PHNs should help families with drug-using children to resolve their problems. Home health nursing could help families to improve their quality of life. Families with drug-using children require support from within the family or the wider social system. Family environment is an essential factor for supporting the development of children [28]. The families perceived that they did not receive any social support and they only received support in the form of information. The provision of advice by communities, personnel, and health care workers to families with drug-using children was perceived as helping emotionally, but support in the form of financial assistance is required when the family is struggling financially due to the costs of treatments and drugs.

The families needed to deal with the attitudes and concerns of the larger family, as well as the community, officials, health workers, and facilities. The attitude of the community was considered to be mediocre when interacting with the family and drug users, and preventative measures were necessary to avoid a stigma, as well as a proactive and assertive attitude by the authorities in order to combat drugs in the area. They also wanted proactive health workers and improved free services for drug users.

In this study, we used a phenomenological qualitative study design, which may have imposed several limitations. First, the interviews were only with parents and this may have biased the findings. Obtaining data from the parents and children might have improved the validity of the data. Second, the periods that the children used drugs and the health services accessed by families should have been identified. Furthermore, the community health centers involved could have been included in the study. Therefore, active research by PHNs during home health nursing should be conducted to identify a comprehensive and holistic program for helping families with drug-using children and improving their quality of life. An intervention study based on health education for children in school health and community health programs should be conducted to promote the health of adolescents and reduce substance abuse. It has been suggested previously that an Indonesian school health promotion program could focus on healthy behavior [29]. This program could evaluate the effectiveness of improving the coordination among parents, schools, and the community to facilitate positive youth development.

Conclusions

Families with drug-using children undergo a process of deep, prolonged, and repeated grieving over several stages comprising of denial, bargaining, anguish, and acceptance. Efforts are made to resolve this problem by families in the form of adaptive coping such as redirecting sadness, spiritual enhancement, and accepting reality. However, the families may also engage in maladaptive coping as a cover to avoid the issue. Families with drug-using children will experience different loads, including physical, economic, social, and psychological loads, as well as social stigma and discrimination. Comprehensive home health nursing should be conducted to support families with drug-using children in many ways via public health nursing interventions. An active research design based on families, children, and nurses will help to identify suitable holistic care for a public health intervention program.

Source funding

The authors did not receive financial support for the research.

Declaration on competing interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Authors contribution

Ritanti (R) and Tantut Susanto (T.S) contributed to the conception and design of this study; R contributed to the acquisition of the data; R and T.S carried out the analysis and interpreted the data; T.S. drafted the manuscript; Wiwin Wiarsih (W·W) and Amalia Dewi Asih (A.D.A) critically reviewed the manuscript and supervised the whole study process. All the authors read and approved the final manuscript.