Barriers to treatment of alcohol and tobacco use disorders in industrial workers.

Background: Substance use disorders (SUDs) are common among industrial workers and often lead to higher absenteeism and lower productivity. Multiple factors may be responsible for hindering the treatment of SUDs among industrial workers. Objective: The study was planned to assess the barriers to treatment of SUDs among workers employed in organized industries and factories. Materials and
Methods: We conducted a cross-sectional study done at a tertiary care hospital associated with medical college in Delhi NCR. A total of 200 participants presenting to medicine outpatient department for the treatment of illnesses other than SUDs were selected by systematic random sampling. Participants consenting for inclusion and fulfilling the Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition criteria for substance dependence were assessed using barriers to treatment inventory and Mini-International Neuropsychiatric Interview 7.0.2.
Results: The most commonly reported barriers to seeking treatment were time conflict (99.5%), followed by the absence of problem (80.5%), fear of treatment (68%), and negative social factors (49%). The absence of problem as a major barrier was reported significantly more in younger male participants, whereas fear of treatment was reported more in younger and unmarried females. Privacy concerns showed significant association with older females whereas negative social support was associated with married urban males. Alcohol dependence was observed to be significantly more in barriers such as admission difficulty, poor treatment availability, privacy concern absence of problem, and poor treatment availability and admission difficulty as a barrier was observed to be more in mild severity of illness.
Conclusion: Educating employees through company wellness programs, Employee Assistance Program, and Work/Life programs to educate them about the harmful effect of substance use and various treatment availability options. Efforts should be made to reduce stigma in the workplaces, making necessary amendments so as to allow workers to have sufficient time for proper rehabilitative services and to ensure the patient about the privacy and confidentiality of the illness and treatment. Copyright:

The ever-increasing complexity of modern life, with its multitude of aspirations and myriad stressors, has precipitated a crisis of substance use disorder (SUD) among all sections of society. SUD is fast emerging as one of the most pressing problems facing the human race in both the developing and the developed countries, with the World Drug Report of 2016 highlighting that of 247 million people who used drugs in 2014, over 29 million people are estimated to suffer from drug use disorders.[1] The consequences of drug use on physical and mental health are particularly devastating, considering the estimated deaths and disability-adjusted life years attributed to substance use every year.[12]

It is vital for people with SUDs to enter treatment regimens early as it helps in rehabilitation and improving outcomes. Unfortunately, a significant proportion of individuals with SUDs does not receive proper treatment.[3] Only 1 in 6 people with SUD reported taking treatment.[1] Andersen found that characteristics of the health-care system as well as individual determinants (predisposing static characteristics, enabling/inhibiting factors, and situational need factors) interact to influence health-care utilization behavior.[4] Such events/characteristics of the individual or the system that serves as obstacles to the person receiving health care or drug treatment may be termed as barriers to treatment.[5]

The unmet need for SUD treatment is not limited to the uninsured. A study in the United States showed that almost half of individuals in need of substance abuse treatment had private insurance.[6] Similarly, in India, much of the organized industrial population is covered under social security schemes such as the employee state insurance scheme, although the treatment utilization is very poor.

As a cohort, industrial workers may have certain limitations, specific predispositions, and vulnerabilities, in context to the treatment-seeking behavior. They form a major task force in developing countries, and SUDs may lead to higher absenteeism and lower productivity.[7] No Indian study has specifically evaluated the barriers to treatment for SUDs among industrial workers. The PubMed search also did not reveal any research conducted on unmet needs for SUD treatment in industrial workers. To address this paucity in research as well as to provide crucial insights into a very important cohort, we conducted our study to assess the barriers to treatment of SUDs among workers employed in organized industries and to evaluate various factors associated with these barriers.

MATERIALS AND METHODS

We conducted a cross-sectional study in the medicine OPD of a tertiary care hospital associated with a medical college in Faridabad, Haryana, catering exclusively to the insured industrial population of nearby areas. The sample size was calculated using the formula n = 4 (pq/L2), where P = population proportion of positive character (approximately 10% from previous prevalence studies), q = 1 – p, and L = allowable error (5%). The study was conducted between September 2019 and December 2019. The study was conducted after obtaining ethical approval from the Institutional Ethics Committee.

Patients seeking treatment from medicine OPD for illnesses other than SUDs were approached and explained the purpose of our study. Those willing were screened for SUD using criteria from the Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition. Patients having SUDs, willing to give written informed consent, aged between 18 and 60 years, employed in organized industries/factories or their family members with monthly income lower than Rs. 21,000 were considered for inclusion in the study. Subsequently, patients were administered the Mini-International Neuropsychiatric Interview 7.0.2 to screen and rule out comorbid psychiatric disorders. The MINI is a brief, structured, and validated interview for screening major Axis I psychiatric disorders.[8] All individuals who were not willing to give written informed consent, who were critically ill, with medical and surgical emergencies, with any present or history of psychiatric disorders (other than SUD, so as to compensate for confounding barriers such as stigma, shame, and lack of family support) were excluded from our study.

The information was collected and recorded using a structured sociodemographic questionnaire, a pro forma having questions related to substance use parameters, and relevant medical records of the patient. The barriers to treatment inventory (BTI) was applied by the investigator during a detailed 30-min interview session with every patient. The BTI was designed specifically for assessing barriers to drug treatment.[9] It is reliable and has good content validity. It comprises 25 items in 7 well-defined constructs: Absence of problem, negative social support, fear of treatment, privacy concerns, time conflict, poor treatment availability, and admission difficulty. Patients are asked to indicate on a Likert scale. For calculation purposes, the mean of the values for each barrier was calculated and <3 was designated as disagree and >3 was designated as agree with respect to the presence/absence of the barrier to treatment.

Analysis was performed by the IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (Armonk, NY: IBM Corp.). The sociodemographic variables were summarized with the help of frequency and percentages. Appropriate parametric and nonparametric statistical tests were used for data analysis. Statistical significance was fixed at P < 0.05.

RESULTS

We interviewed 1296 participants for enrolment in the study, out of which 292 fulfilled the inclusion criteria. Among these 292 participants, 34 did not give consent for inclusion, while 58 had significant medical and psychiatric comorbidities. Out of 200 eligible study participants, 182 (91%) were male and 18 (9%) were female. The most prevalent SUDs were nicotine (60.5%), followed by alcohol (48.5%). More than 81% participants had a history of substance use for >6 months [Tables 1 and 2].

Table 1

Sociodemographic variables of study participants and correlation with barriers to treatment

Parameters	Percentage	Fear of treatment, n (%)	Time conflict, n (%)	Admission difficulty, n (%)	Poor treatment availability, n (%)	Privacy concern, n (%)	Absence of problem, n (%)	Negative social support, n (%)
Total (n=200)	136 (68)	199 (99.5)	70 (35)	69 (34.5)	81 (40.5)	161 (80.5)	98 (49)
Gender
Male (n=182)	91	118 (64.8)	181 (99.5)	55 (30.2)	54 (29.7)	65 (35.7)	152 (83.5)	97 (53.3)
Female (n=18)	9	18 (100)	18 (100)	15 (83.3)	15 (83.3)	16 (88.9)	9 (50)	1 (5.6)
P	0.002*	0.753	0.0001*	0.0001*	0.0001*	0.001*	0.0001*
Age (years)
<35 (n=139)	69.5	116 (83.5)	139 (100)	33 (23.7)	31 (22.3)	43 (30.9)	123 (88.5)	66 (47.5)
>35 (n=61)	30.5	20 (32.8)	60 (98.3)	37 (60.7)	38 (62.3)	38 (62.3)	38 (62.3)	32 (52.5)
P	0.0001*	0.130	0.0001*	0.0001*	0.0001*	0.0001*	0.517
Marital status
Married (n=160)	80	102 (63.8)	160 (100)	64 (40)	62 (38.8)	67 (41.9)	131 (81.9)	85 (53.1)
Unmarried (n=40)	20	34 (85)	39 (97.5)	6 (15)	7 (17.5)	14 (35)	30 (75)	13 (32.5)
P	0.010*	0.45	0.003*	0.011*	0.428	0.326	0.020*
Religion
Hindu (n=162)	81	114 (70.4)	161 (99.4)	59 (36.4)	58 (35.8)	96 (40.7)	137 (84.6)	162 (48.1)
Muslim (n=16)	8	10 (62.5)	16 (100)	6 (37.5)	6 (37.5)	7 (56.2)	6 (37.5)	16 (68.8)
Others (n=22)	11	12 (54.5)	22 (100)	5 (22.7)	5 (22.7)	16 (27.3)	18 (81.8)	22 (40.9)
P	0.291	0.889	0.440	0.464	0.197	0.0001*	0.210
Residence
Rural (n=9)	4.5	88.9 (8)	100 (9)	4 (44.4)	4 (55.6)	4 (44.4)	6 (66.7)	1 (11.1)
Urban (n=191)	95.5	128 (67)	190 (99.5)	66 (34.6)	65 (34)	77 (40.3)	155 (81.2)	97 (50.8)
P	0.169	0.828	0.543	0.521	0.067	0.284	0.020*
Family type
Nuclear (n=176)	88	118 (67)	175 (99.4)	67 (38.1)	66 (37.5)	75 (42.6)	139 (79)	89 (50.6)
Joint (n=24)	12	18 (75)	24 (100)	3 (12.5)	3 (12.5)	6 (25)	22 (91.7)	9 (37.5)
P	0.230	0.711	0.014*	0.016*	0.099	0.433	0.230
Salary (per month)
<10,000 (n=35)	17.5	30 (85.7)	35 (100)	8 (22.9)	7 (20)	19 (54.3)	32 (91.4)	18 (51.4)
>10,000 (n=165)	82.5	106 (64.2)	164 (99.4)	62 (37.6)	62 (37.6)	62 (37.6)	129 (78.2)	80 (48.5)
P	0.013*	0.644	0.097	0.047*	0.067	0.072	0.752
Education
12 below (n=110)	55	78 (70.9)	110 (100)	38 (34.5)	36 (32.7)	49 (44.5)	87 (79.1)	53 (48.2)
12th or above (n=90)	45	58 (64.4)	89 (98.9)	32 (35.6)	33 (36.7)	32 (35.6)	74 (82.2)	45 (50)
P	0.330	0.268	0.882	0.560	0.198	0.578	0.798

*Significant at P < 0.05

Table 2

Substance-related variables of study participants and correlation with barriers to treatment

Parameters	Percentage	Fear of treatment, n (%)	Time conflict, n (%)	Admission difficulty, n (%)	Poor treatment availability, n (%)	Privacy concern, n (%)	Absence of problem, n (%)	Negative social support, n (%)
Total	136 (68)	199 (99.5)	70 (35)	69 (34.5)	81 (40.5)	161 (80.5)	98 (49)
Substance use type
Alcohol (n=97)	48.5	70 (72.2)	97 (100)	26 (26.8)	26 (26.8)	32 (33)	84 (86.6)	51 (52.6)
P	0.220	0.331	0.018*	0.026*	0.036*	0.035*	0.326
Nicotine (n=121)	60.5	80 (66.1)	121 (100)	47 (38.8)	45 (37.2)	51 (42.1)	100 (82.6)	60 (49.6)
P	0.480	0.215	0.158	0.322	0.557	0.343	0.837
Others (n=23)	11.5	13 (59.1)	22 (100)	10 (45.5)	10 (45.5)	13 (59.1)	11 (50)	8 (36.4)
P	0.342	0.725	0.276	0.252	0.06	0.00001*	0.209
Duration of SUD (months)
<6 (n=38)	19	35 (92.1)	38 (100)	10 (26.3)	9 (23.7)	14 (36.8)	34 (89.5)	14 (36.8)
>6 (n=162)	81	101 (62.3)	161 (99.4)	60 (37)	60 (37)	67 (41.4)	127 (78.4)	84 (51.9)
P	0.0001*	0.627	0.212	0.119	0.610	0.121	0.096
Severity
Mild (n=74)	37	55 (74.3)	74 (100)	35 (47.3)	34 (45.9)	35 (47.3)	59 (79.7)	29 (39.2)
Moderate (n=94)	47	58 (61.7)	93 (98.9)	28 (29.8)	28 (29.8)	35 (37.2)	72 (76.6)	54 (57.4)
Severe (n=32)	16	23 (71.9)	32 (100)	7 (21.9)	7 (21.9)	11 (34.4)	30 (93.8)	15 (46.9)
P	0.193	0.587	0.015*	0.024*	0.311	0.104	0.061
Past history of seeking treatment
Present (n=50)	25	39 (78)	49 (98)	18 (36)	20 (40)	26 (52)	18 (36)	26 (52)
Absent (n=150)	75	97 (64.7)	150 (100)	52 (34.7)	49 (32.7)	55 (36.7)	143 (95.3)	72 (48)
P	0.080	0.705	0.864	0.345	0.056	0.001*	0.624

SUD Substance use disorder. *Significant at P < 0.05

The most commonly reported barriers to seeking treatment were time conflict (99.5%), absence of problem (80.5%), fear of treatment (68%), and negative social factors (49%). Privacy concerns (40.5%), admission difficulty (35%), and poor treatment availability (34.5%) were reported to be less common [Table 1].

Time conflict was the most common reason for not seeking treatment in almost all of the study sample (99%). The absence of problem was significantly associated with male, <35 years of age and with religion other than Muslims. Significant association was found between fear of treatment and female, <35 years age, unmarried participants and with income <10,000 rupees/month. Negative social support was significantly associated with males, married participants, and those belonging to urban areas. Privacy concern was significantly associated with female, >35 years of age. Admission difficulty was significantly associated with female >35 years age, married participants, and nuclear family. Poor treatment availability was significantly associated with female, >35 years of age, married participants, nuclear family and with income >10000 rupees [Table 1].

Fear of treatment as a barrier was found more in those with duration of substance use <6 months. The absence of problem was associated more in people with alcohol dependence, using other substances and history of treatment for substance use. Privacy concern was found to be a more in those with alcohol dependence. Poor treatment availability was associated more in alcohol dependence and mild severity of substance use. Admission difficulty was associated with alcohol dependence and mild severity of substance use.

DISCUSSION

The results obtained from our study throw much-needed light on different barriers to seeking treatment for SUDs by the most vulnerable subset of our nation's workforce. These barriers to seeking treatment derail the individual's ability to lead a satisfying and productive personal and professional life thus causing significant social and economic detriment.

Time conflict was the most common barrier among industrial workers. Almost all the participants reported time constraints as one of the reasons for not taking treatment. It could be because of similar operational timings of industries as well as the hospitals providing deaddiction services. A possible solution to mitigate this barrier would be to provide health-care services in community outreach programs dedicated to industries, having a provision for workplace authorized leave with no cut in pay when seeking substance-related treatment and possibly setting up evening clinics and arranging for teleconsultation at workplace. Previous studies have findings in concordance with our study, but they were not conducted among industrial workers.[1011]

The absence of problem was found to be the second most common barrier, significantly associated with male participants <35 years of age which is in line with the study done by Kharrazi et al.[10] We found that people who had sought treatment in the past accepted the substance use problems better, which is similar to studies done by Hajema et al. and Kleinman et al.[1213] Alcohol-dependent participants reported the absence of problem as a common reason for not seeking treatment, which may be due to poor insight and motivation. Our findings were in concordance with the study by Kumar et al.[14] The absence of problem was less significant barrier in Muslims as compared to other religions, as Muslim religion prohibits the use of alcohol and other psychoactive substances.[15] Employees should be educated about the health and productivity hazards of substance abuse through company wellness programs, Employee Assistance Programs (EAPs), Work/Life programs, and motivated to accept the problem and seek treatment.

Fear of treatment was significantly associated with younger unmarried females with income 11] Participants who had lesser duration of substance use (<6 months) were more afraid of seeking treatment, which may be associated with stigma or guilt of accepting the condition. Apprehension and fear of treatment can be postulated to have multiple reasons such as lack of awareness of treatment options, doubts regarding efficacy and side-effects of medications, cost of treatment, negative peer/social pressure, and unpleasant past personal experiences.

Negative social support as a significant barrier was associated with male sex, married participants which is in contrast with the study by Barman et al., Kharrazi et al., and Jackson and Shannon which reported females to be having lack of social support as a significant barrier.[101118] These differences are understandable due to the different sociodemographic representation of patients, where males in India are responsible for livelihood of the family, and thus, prolonged treatment and rehabilitation by male member are often not supported. Furthermore, psychological help-seeking behavior by “males” is not easily accepted by the patriarchal society and may have adverse impact on social image and workplace (industries). Negative social support was also significantly associated with urban population as majority of people who live in urban areas have small families in contrast to rural area. To mitigate this barrier, we should help patients in seeking treatment by educating their families about substance use, organizing community programs and involving treating physician, NGOs, and rehabilitation team to work together in supporting them.

Privacy concern was reported to be significantly associated with females and >35 years of age. This corroborates with the study done by Barman et al. and Allen.[1117] Alcohol-dependent participants had more privacy concerns in comparison to other substances, as was seen in studies done by Cunningham et al. and Kumar et al., which also identified inability to share problems with others as the major barrier in seeking treatment.[1419] To mitigate this barrier, patients should be ensured about confidentiality of their illness and treatment they seek.

Poor treatment availability as a barrier was found more in females which is line with the study done in rural Punjab.[11] Females may face difficulty availing treatment facilities either due to distance, lack of transportation or unavailability of special clinics near homes. Elderly people and married participants belonging to nuclear family reported significantly more difficulty in availing treatment. This may be attributed to policy issues related to treatment and hospital availability, poor financial support, absence of appropriate services for vulnerable groups such as women, elderly, and those having low social support.[202122] Mild severity of alcohol dependence also significantly correlated with poor treatment availability. Addiction services mainly focus on more severe presentations due to lack of infrastructure for deaddiction and shortage of trained manpower. Factors hindering treatment for mild cases of alcohol dependence have not been adequately studied and reported before and require further research.

Admission difficulty as a barrier was associated with females which corroborates with study by Kharrazi et al. and Jackson and Shannon[1018] A study by Allen reports that females having children encounter more admission difficulty as they are worried for well-being of their children and family.[17] Caring for the family amidst low social support may also be the reason why admission difficulty was reported as a barrier among older married participants and those living in nuclear family. Participants with mild severity of alcohol use faced more difficulty with admission as criteria lay more focus on moderate to severe alcohol dependence for admission, and hospital staff may not perceive their problems seriously.

Our study is the first one in India to focus on barriers to treatment among organized industrial workers. With growing industrialization and problem of drug abuse among industrial workers, India faces a huge burden in terms of increased expenditures for health care, workplace injuries, disability payments, and productivity losses. Our study provides crucial insights and will be of service to employers and agencies in devising policies to address and manage these barriers to treatment. Limitations of our study include small sample size, poor representation of female participants, and participants dependent on opioids, cannabis and with polysubstance abuse. Addressing these limitations would greatly aid in advancing our understanding of the complex interplay between the various barriers to treatment and thus help in alleviating the treatment-related hesitancy and fear faced by a majority of people with SUD.

CONCLUSION

It is evident from the results that different barriers to treatment exist in correlation with one another, and tackling them independently in isolation is less likely to yield optimal rewards with regard to greater acceptance or willingness to seek treatment for substance abuse-related problems. Various measures should be undertaken for educating employees about the health and productivity hazards of substance abuse through company wellness programs, EAPs, and work/life programs. Reducing stigma in the workplaces, stricter regulation of all facilities dealing with substance abuse patients, adherence to labor law codes concerning medical leave for seeking treatment and making necessary amendments so as to allow for sufficient time for proper rehabilitative services will be of utmost help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.