Utility of special drive campaign on substance use disorders in hard-to-reach communities in the fast urbanizing town of Solan, India.

AIMS: Special drive campaigns on substance use disorders (SUDs) in India are usually organized in educational institutes, non-governmental organizations, or few selected localities. Hard to reach communities of construction, prison, and industrial sites quite often remain uncovered.
MATERIALS AND METHODS: During a month-long special drive in 2019, under a cross-sectional study, we reached these communities of Solan town through awareness camps and incorporated standardized screening tools for evaluating morbidity patterns of SUDs.
RESULTS: Statistically significant relationship existed between 360 participants (90.8% males, 9.2% females; mean age of 33 years) and their educational levels with χ2 (1, n = 360) =130.59, P = 0.000. Fagerstrom's scale inferred very high nicotine dependence in 10.6%, 7.9%, and 2.4% of prisoners, industrial workers, and laborers, respectively. Whereas, Fagerstrom scale for smokeless tobacco revealed 31% of significant dependence potential amongst laborers. Alcohol use disorder identification test revealed 28 persons with harmful alcohol dependence. Drug abuse screening test revealed 13.6% of prisoners having moderate level drug abuse potential. The Kruskal-Wallis test showed a statistically significant difference, in levels and potential of substance use in construction, prison, and industrial sites.
CONCLUSION: The study proved the utility of special drives in evaluating SUDs morbidity patterns in hard-to-reach communities. Copyright:

INTRODUCTION

India has an international commitment to curb substance use disorders (SUDs). The country is a signatory to three United Nations Conventions namely (a) Convention on Narcotic Drugs, 1961; (b) Convention on Psychotropic Substances, 1971 and (c) Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988. Under its ambit, the Ministry of Social Justice and Empowerment has been implementing the Scheme of Prevention of Alcoholism and Substance/Drug Abuse since 1985–1986 in the country. The guidelines on SUDs focus on strengthening the workplace prevention program, de-addiction camps, awareness, and prevention programs on SUDs and innovative interventions to strengthen community-based rehabilitation along with other strategies such as surveys, studies, evaluation, and research on SUDs.[123] These guidelines focus on prevention and interventions for the management of SUDs.[4567]

The country with huge resource constraints due to overpopulation, poverty, and illiteracy, still has been putting in efforts to fight SUDs. Special drives or campaigns are often conducted to give acceleration to achieve the goals of amelioration of the menace of substance use. These campaigns are driven by a specific timeline frame and result in the collection of a range of health information in a short period. The special drives, galas, rallies, conferences, contest, festivals, walks/runs, sports competitions, etc., are all means to educate about substance use/drugs. Most of the time, these camps or the special drive campaigns get organized at the level of educational institutes, offices, nongovernmental organizations, or at the most in certain selected colonies of a region. These campaigns evolve mainly around the spread of health promotional messages. Areas such as industries, prison or construction sites resist organization of such events or campaigns due to reasons such as time constraint affecting the working output of the unit or construction site, security reasons, especially in prison settings. Moreover, there is an overall resistance of the organizers of these campaigns itself to reach to these communities due to lots of technical and administrative difficulties involved.

Various health promotional activities are planned and executed during the special drives or campaigns on the prevention of substance use in the community. These focus precisely on the components of providing platform for how to avoid, stop or get help for SUDs.[8] These interventional initiatives also prove to be cost-effective in terms of management of the problem of substance use.[910] These, in the shape of drives or campaigns, may be implemented in the communities as such, or high-risk areas within the community or families affected by the SUDs itself.[11] Long-running campaigns sometimes do not pay dividends and may at the other times prove totally cost-ineffective.[12] Whereas, targeted campaigns prove beneficial with the special design of the campaign which specifically works on a group of clients.

Screening, i.e, evaluating the possible presence of the substance use problem in the community gets an impetus during special campaigns and drives. It is a very important community diagnostic tool. Campaigns or special drives envisaging screening of the masses involve gathering key information and engaging with the community for a better understanding of the problem areas pertaining to substance use amongst the clients.

Solan district of the state of Himachal Pradesh in the northern part of India is a fast urbanizing and industrializing region and features the problems associated with migratory population dynamics. During the year 2019, a month-long special drive on drug abuse and alcoholism was organized throughout the state w.e.f. November 15, 2019–December 15, 2019, with the aim to reach different facets of society for eliciting the substance use problem and implement steps for curbing it. We designed a study within this drive in the resource-constrained settings of Solan district with the objectives of eliciting the substance use level in hard-to-reach communities and disseminating the knowledge in these communities about substance use.

MATERIALS AND METHODS

Study design

It was a cross-sectional study with health promotional interventional activities.

Study area

The study was carried out at three places, namely a construction site, the district Prison, and an industrial unit adjoining the Solan town of the district. The three sites were purposively selected based on their vicinity to the district level de-addiction center of the Regional Hospital of Solan, to meet the demands of any follow-ups of the study.

Sample size

All the 360 volunteer participants of the study sites, who had consented for the study, were enrolled for the study.

Study population

Forty-two laborers working in the construction site, 66 prisoners, and 252 workers of the industry of the Solan town participated in the study.

Operational definition

We decided to enroll all the voluntary participants of the three sites of the study.

Study tool

Four different instruments, i.e. the standardized substance use screening tools were employed in the study [Table 1]. These were the Fagerstrom Test for Nicotine Dependence (FTND), FTND-Smokeless Tobacco (ST), and Alcohol Use Disorder Identification Test (AUDIT), and Drug Abuse Screening Test (DAST).

Table 1

Description of screening tools for assessment of substance use disorders

Screening tool	Score inference
Fagerstrom test for nicotine dependence	Dependence potential
	Very low: 0-2
	Low: 3-4
	Medium: 5-7
	Very high: 8-10
Fagerstrom test for nicotine dependence- smokeless tobacco	Dependence potential
	Low: ≤4
	Moderate: 5-7
	Significant: ≥8
Alcohol use disorder identification test	Level of alcohol use
	Harmful and hazardous: ≥8
	Medium level: 8-15
	High level/possible alcohol dependence: ≥16
Drug abuse screening test	Abuse potential level
	Low: 1-5
	Moderate: 6-10
	Substantial: 11-15
	Severe: 16-20

These tools were used as questionnaires and the study participants were assessed accordingly.

Printed pamphlets providing information about the harmful health effects of substance use were distributed in the awareness camp organized during this drive at all the study regions. The information material was printed in the local language, i.e. Hindi (also being the national language). Banners were also displayed at each of the study regions, depicting the informational messages about substance use and its ill effects on health. The information, communication, and educational material used during the camps focused on health promotional steps and activities to be undertaken at the community level to fight with the problem of SUDs.

Study period

The study was conducted during the 1 month period of the special drive, i.e, November 15, 2019–December 15, 2019.

Data collection and statistical analysis plan

The data on the screening tools were collected by the principal investigator and two trained members of the De-addiction center of the Regional Hospital of Solan town. The standardized questionnaire-based screening tools were administered in local language Hindi to the study participants. The permission for the study was duly secured from the office of the Chief Medical Officer, Solan, Himachal Pradesh. The participants were duly informed about the purpose of the study and written consent was sought from them. The participants were given the choice that at any time of the study they could leave the study without ascertaining any reasons and that this would not debar them from availing the other services of the special drive.

The collected data were collated in Microsoft Excel Spreadsheet. The respondents were coded appropriately for maintaining the confidentiality of the individual participants. The data cleaning was ensured for any possible errors. The statistical analysis was carried out by using the IBM Statistical Package for the Social Studies, version 21.0.

Pearson's Chi-square test of independence was used to evaluate differences between the categorized variables. The normally distributed data were depicted as means and standard deviations (SDs). The tests were performed at 5% level of significance inferring that the associations were significant if the P < 0.05. The Kruskal–Wallis test was used for analyzing the pattern of the screening tools across the three study settings i.e, the construction, the prison and the industrial site. Post hoc analysis was conducted by using the Mann–Whitney U test.

RESULTS

A total number of three awareness camp were organized, one at each of the study region, during the month-long special drive. All 360 participants attended these camps. The data are illustrated in Table 2 depicts the mean age, gender (males-90.8%), SD, and standard error, of the study participants of the construction site, prison, and the industrial unit of the Solan town.

Table 2

Demographic description of study subjects by various study regions

Study region	Males	Females	Total	Mean age (years)	SD	SE
Construction site	29 (69)a	13 (31)	42	24.86	6.51	1.01
Prison	60 (91)	6 (9)	66	34.68	14.47	1.78
Industrial unit	238 (94.4)	14 (5.6)	252	33.96	9.33	0.58
Total	327 (90.8)	33 (9.2)	360	33.03	10.61	0.55

a Figures in parenthesis represent percent. SD - Standard deviation; SE - Standard error

The data in Table 3 inferred that about half of the laborers, 35.7% of the prisoners and 14.3% of the industrial workers were illiterate. The Chi-square test of independence showed that the relation between the study participants and their respective educational levels was statistically significant, χ2 (1, n = 360) =130.59, P = 0.000.

Table 3

Educational status of various study regions

Educational status	Study region			Total	χ2, P
	Construction site	Prison	Industrial unit
Illiterate	7 (50) a	5 (35.7)	2 (14.3)	14 (100)	130.59, >0.001
Primary school	13 (48.1)	9 (33.3)	5 (18.5)	27 (100)
Middle school	7 (26.9)	9 (34.6)	10 (38.5)	26 (100)
High school	12 (18.5)	16 (24.6)	37 (56.9)	65 (100)
Intermediate school	2 (1.3)	12 (7.6)	143 (91.1)	157 (100)
Graduate	1 (2.4)	8 (19)	33 (78.6)	42 (100)
Professional	0	7 (24.1)	22 (75.9)	29 (100)
Total	42 (11.7)	66 (18.3)	252 (70)	360 (100)

a Figures in parenthesis represent percent

Table 4 depicts the number of substance users of the three study settings namely the construction, prison, and industrial site. The Fagerstrom tool elicited a very low dependence potential on nicotine in 7.1%, 1.5%, and 2.4% of the laborers of the construction site, prisoners, and workers of the industrial site, respectively. Whereas, 10.6% of prisoners had a very high dependence potential followed by 7.9% and 2.4% of industrial workers and laborers, respectively. The Modified Fagerstrom tool for ST revealed a high of 31% of significant and 33.3% low-to-moderate dependence potential on ST among the laborers. The AUDIT scale had evinced a total number of 28 persons who had harmful and hazardous/possible alcohol dependence (dependence score ≥8). High level of alcohol dependence was inferred by the AUDIT tool in 12.1% of the prisoners. Medium level of dependence was also observed variably among the laborers, prisoners, and industrial workers. Abuse potential for drugs was observed more in the prisoners with about 13.6% of the prisoners having moderate level of abuse potential.

Table 4

Screening tool scores in the substance users in Solan town, 2020

Screening tool	Scores	Frequency
		Construction site (n=42)	Prison (n=66)	Industrial site (n=252)
Fagerstrom test for nicotine dependence	Very low	3 (7.1)*	1 (1.5)	6 (2.4)
	Low	1 (2.4)	6 (9.1)	8 (3.2)
	Medium	0	7 (10.6)	2 (0.8)
	Very high	1 (2.4)	7 (10.6)	20 (7.9)
Fagerstrom test for nicotine dependence-smokeless tobacco	Significant	13 (31)	8 (12.1)	5 (2.0)
	Low to moderate	14 (33.3)	7 (10.6)	9 (3.6)
Alcohol use disorder identification test	Medium	3 (7.1)	1 (1.5)	13 (5.2)
	High	0	8 (12.1)	3 (1.2)
Drug abuse screening test	Low	1 (2.4)	5 (7.6)	4 (1.6)
	Moderate	0	9 (13.6)	2 (0.8)
	Substantial	0	2 (3.0)	0
	Severe	0	1 (1.5)	0

*Figures in parenthesis indicate percent

The Kruskal–Wallis H test showed that there was a statistically significant difference in the nicotine dependence potential between the different community settings of the construction site, prison, and industrial unit, χ2 (2) =11.80, P = 0.003, with mean rank nicotine dependence potential score of the Fagerstrom test being highest for the prison settings and lowest for the construction site [Table 5].

Table 5

Kruskal-Wallis H test for screening of substance use in Solan town, 2019

Study region	Number of study participants	Mean rank values
		Fagerstrom test for nicotine dependence	Fagerstrom test for nicotine dependence- smokeless tobacco	Alcohol use disorder identification test	Drug abuse screening test
Construction site	42	169.08	267.74	178.52	172.62
Prison	66	206.28	193.14	204.39	215.29
Industrial unit	252	175.65	162.65	174.57	172.70
χ2, P		11.80, 0.003	95.489, 0.000	15.544, 0.000	48.315, 0.000

The table also evinced a statistically significant difference shown by the Fagerstrom test for ST, in the dependence potential of ST amongst the settings of the construction site, jail and the industrial unit, χ2 (2) =95.48, P = 0.000. The mean rank observed for the ordinal data of the dependence potential of ST was observed to be highest in the construction site and lowest in the industrial unit.

The data enumerated in the table also depicts a statistically significant difference in the level of alcohol use in the construction site, prison, and industrial unit, χ2 (2) =15.54, P = 0.000 with the highest ranking of AUDIT for the prison and lowest for the construction site. Whereas, the abuse potential level of the drugs, inferred by the DAST scale, also varied significantly across the settings of the construction site, jail, and the industrial unit, χ2 (2) =48.31, P = 0.000 with the highest mean rank abuse potential level score in prison and lowest in the construction site.

Post hoc analysis by Mann–Whitney U test however did not show any significant difference among any of these two sites.

DISCUSSION

The study has highlighted the usefulness of special drives or campaigns which are organized to fight SUDs in the population settings which remain the left out ones for one or the other reason. Within a very short period of 1 month such three different facets of the community were approached which otherwise usually remain aloof from such awareness camps or drives. Usually, the drives or campaigns on SUDs are arranged at the level of educational institutes,[13] nongovernmental organizations or at the most in certain high risk areas or communities/localities of a region. No such camps had ever been organized with these three communities in the Solan district. Reaching to the laborers working in a construction site, prisoners within the boundaries of prison and workers of industry was a new innovative component added by our study. Chavan and Gupta have also documented that community based model of care was effective in reaching the persons who were unaware of the fact that they were already suffering from SUD.[14] The present study had elicited persons suffering from alcohol dependence. These persons were thereafter counseled to report to the de-addiction clinic of the Regional Hospital where still they shall be receiving continuous care and treatment. Murthy et al.[15] and Kar et al.[16] had also inferred from their study that community visits and continuous care pay dividends in alcohol de-addiction.

Gururaj et al. documented that although an alarming overall prevalence of substance use of 22.4% in India still very less has really been done at the level of prisons or construction/industrial sites to have real-time assessment of the burden of substance use.[17] These are the resource-constrained settings where the security or the work gets compromised and such drives or campaigns are not allowed to happen. The present study was an initiative in this regard which not only had offered health promotional messages during the awareness camps but also had elaborated in these settings the various levels of dependence potential for nicotine products, abuse potential for various drugs, and varying levels of alcohol use. The present study has elicited that the substance of abuse in prison settings was mainly nicotine (smoked), ST, alcohol, and prescription drugs. Among the industrial workers, smoked nicotine was the main substance of abuse. Though, the industrial workers were also abusing the ST and alcohol. The labourers were mainly abusing the ST. Giri et al. in a study near Chandigarh, a region near to the study region, had similarly proved a positive impact of awareness camps in community in amelioration of SUDs prevalent in the region and had documented that the camps or drives were cheap, effective treatment alternatives which were time-bound and objective defined.[18] Pearson and Lipton[19] and Wild et al.[20] evinced in their respective studies the evidence elsewhere that working with prisoners in the domains of promoting health education about SUDs, reduces the frequencies of re-offending and drug dependency. Our study had inferred a high proportion of drug abuse in prison settings. Dolan et al. in a study had similarly documented the drug problem ranging between 40% and 80% amongst the prisoners.[21]

The present study has also evinced that the labor class, having a high level of illiteracy levels, suffers from a huge burden of SUDs, especially the use of ST which was observed as a prominent feature among the laborers. A very less evidence is available in India in regard to the assessment of drug awareness campaigns in the construction sites. Data eliciting substance use burden among the workers involved in construction was largely lacking. Jayakrishnan et al. documented the high risk behaviors in the labor class of construction sites and their low illiteracy levels.[22] Similarly, Desai had also studied the various facets of the basic services and social infrastructure of the laborers of construction sites and observed the low literacy level and high-risk behaviors among the laborers as important determinants of their health.[232425]

The workplace environment is crucial for the good health of the workers along with the economic benefits. Malick in a study in 2018 had similarly analyzed the prevention and management of substance use at workplaces.[2627]

Limitations of the study

As the special drive campaign was a time-bound activity of 1 month, we could only reach three hard-to-reach areas. Moreover, getting permission from the respective In-charge of these field areas for eliciting the substance use behavior was itself a challenge.

CONCLUSION

The study highlighted that the organization of the special drive campaigns should also focus on hard-to-reach communities. The application of the screening tools for eliciting the morbidity pattern of SUD, in these communities during the study not only benefitted the study participants to know about their disorder status but also paved a pathway for de-addiction of these persons in the De-addiction Center of the Regional Hospital. Further follow-up studies are now needed to see the long-term impact of this special drive campaign.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.