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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 57-62

Overcoming barriers to community participation in drug dependence treatment: An ethnography approach


1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, All Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Psychiatry, S. H. K. M. Government Medical College, Nalhar, Haryana, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Bir Singh Chavan
Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.200087

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  Abstract 

Introduction: Substance use and dependence has been a part of Indian society for centuries. However, abuse of more hazardous drugs including intravenous use, younger age of initiation, and high prevalence has made it a major public health issue. Community-based interventions for drug/alcohol use are often hindered by a lack of community participation, which is the result of stigma associated with drug/alcohol use and its treatment. We describe our attempt to address this issue of lack of community participation in a particular community of Dhanas, Chandigarh, using an ethnography approach. Methodology: Despite drug/alcohol use being rampant in their community, the leaders of the community (Sarpanch and Medical Officer of Primary Health Centre) not only denied the problem, but also refused to support community outreach team. In the absence of facilitation by community leaders and prevalent stigma, drug/alcohol users from the Dhanas village did not seek treatment even when the treatment was offered close to their homes. Using an ethnography approach, a 6 point questionnaire was developed to investigate the severity of the problem as well as to engage the community leaders in the delivery of community-based treatment. Results: The questionnaire highlighted that key leaders chose to deny existing drug/alcohol problem whereas those who were aware of the problem did not have a say in the decision-making process. The questionnaire facilitated a thorough understanding of the sociocultural and political ethos of the community which in turn helped in chalking out an action plan in this village. Conclusion: With the help of various individuals such as former and current healthcare workers, community leaders, drug users, and their family members, the community outreach team successfully mobilized the community from denial to activism. This was evident in the number of individuals seeking treatment for drug/alcohol use that showed an increasing trend over the months.

Keywords: Community mental health, community participation, drug and alcohol use, ethnography


How to cite this article:
Chavan BS, Patra S, Gupta N, Rozatkar AR. Overcoming barriers to community participation in drug dependence treatment: An ethnography approach. Indian J Soc Psychiatry 2017;33:57-62

How to cite this URL:
Chavan BS, Patra S, Gupta N, Rozatkar AR. Overcoming barriers to community participation in drug dependence treatment: An ethnography approach. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Jan 22];33:57-62. Available from: https://www.indjsp.org/text.asp?2017/33/1/57/200087


  Introduction Top


Prevalence of substance abuse in any community is determined by a multitude of factors such as sociocultural and political factors in addition to the biological predispositions and immediate environment of the individuals.[1] Who takes which drugs and when are determined by the social, cultural, and religious forces working in the community. The way a drug user perceives himself and the way he is being responded to by others are also determined by the society he lives in.[2]

In the Indian scenario, all the principal drugs of abuse and dependence; opium, cannabis, and alcohol have been used historically.[3] A distinctive feature of drug use in India is its association with social rituals, customs, and religious beliefs. Socioeconomic changes in the postindependence era and westernization of the society are bringing changes in the drug using behavior in India; use of drug/alcohol is rising and even females have started using alcohol.[4] In Punjab, alcohol is part and parcel of celebrations, festivities, and marriages.[5] It is reported that Punjab is gradually falling into the clutches of drug abuse; once healthy youth are now becoming emaciated and hooked to drugs.[6] Drug use in Punjab was recently highlighted in political debates, and subsequently, the government is taking appropriate measures.[7]

Community participation is an educational and empowering process in which people, in partnership with those who are able to assist them, identify the problems and their needs and increasingly assume responsibilities themselves to plan, manage, control, and assess the collective actions that are proved necessary.[8] Thus, for any community level action to succeed, it should address the need of the community, for example, the community should feel there is a problem and that the intervention should be generally acceptable. This “acknowledgment of the problem” may be hindered when society is prejudiced to certain diseases. Stigma associated with any health disorder problem is a significant barrier in providing community-based care. Mental disorders including substance dependence, epilepsy and HIV/AIDS, probably bear the greatest stigma in our society.

In this particular paper, we describe a community where community participation/involvement in alcohol and drug use treatment was itself a major barrier. Multitude of factors prevented the acknowledgment of alcohol use problem in the community and the consequent denial of the problem resulted in resistance to community-based intervention. The present study is an ethnographic account of a rural community in Chandigarh, which is currently struggling with the problem of drug abuse and the process of its transition from being in denial to that of active participation.


  Methodology Top


The Department of Psychiatry, Government Medical College and Hospital, Chandigarh, is providing community services in and around Chandigarh through Community Outreach Clinics (COCs) for the last 15 years. The COC team comprises of a psychiatrist, a nurse and a social worker and provides services in the designated location in morning hours. The COCs are run on a weekly basis at four places in the periphery of Chandigarh. In addition, the community outreach services also include de-addiction camps as well as home-based detoxification services. The epidemiological study carried out in these areas has shown a high prevalence of substance abuse and huge treatment gap.[9] In addition to routine clinical services, the team also works toward improving community awareness about common mental disorders and substance use disorders in the community.

Dhanas, a village which existed even before the establishment of Chandigarh (1960s) is about 15 km away from Government Medical College and Hospital, Chandigarh. It has a population of about 22,000. A large segment of the village called Milk Colony was created by providing land on concessional rates to people having cattle. Thus, rearing of cattle and selling milk is the main occupation of the people. However, the village now is also inhabited by people who have migrated from other states for better employment opportunities. Thus, the village now has a mixed type of population with Sikhs constituting the majority.

During a meeting with the community team in the early 2010, the Sarpanch (head) of the village and medical officer held a view that the village did not have significant problems of substance abuse and hence does not need de-addiction services. However, the community team after gathering information from many other sources in the community such as police officials and auxiliary health workers came to the conclusion that substance abuse was a major problem in the community. In view of the resistance shown by community leaders, we emphasized on information, education, and communication activities such as pamphlet distribution, making announcement from Gurudwaras, using posters at various places, 1-day de-addiction camp, and arranging theatrical play on drug use during Ram-Leela to motivate individuals to seek treatment. Apart from some inquiries made by family members, there was no response from the community.

As the next step, based on the information provided by current and previous Anganwadi workers, we decided to make home visits to know individuals with drug use problem. Initially, about 25 houses were visited. In nearly all cases, family members acknowledged the problem but refused to take treatment either at their home or any other treatment set-up. The reason cited included that they can manage on their own, that the elders of the family emphasize on taking sacred vow of abstinence rather than medical treatment, and that the visit of COC team brings disgrace and humiliation to the family. Indeed, revisits to such individuals were hostile to the point of refusal to open the door. It became evident that the social milieu and societal stigma were road blocks which we could not circumvent unless community leaders themselves were not convinced of the drug use problem in their community. The community team took it as a challenge and decided to work closely with the community for understanding the reasons of denial of the problem and refusal of services.

Since the department was working in the surrounding area for the last 15 years, the ethnographic details were known to the community outreach team. A community intervention plan was devised in which a list of important people from the community representing different groups was prepared. A brief questionnaire in Hindi was prepared to gather information on six questions: (a) Do you think drug and alcohol use is a problem in your village? (b) Which is the most common substance abused in the community? (c) How severe is the problem? (d) How is it affecting the community? (e) How has the community reacted to it? f) Do you think the community needs de-addiction facilities? The psychiatrist as well as the psychiatric social worker made home visits to get first-hand information. In-depth interviews were held with key informants using the questionnaire.


  Results Top


Key informants identified by the investigators included current substance users, ex-users, religious leaders, family members of the users who earlier sought treatment from the hospital-based de-addiction services, women and youth organizations, and the medical officer of the Dhanas civil dispensary. The prepared questionnaire was applied to the key informants of Dhanas community. Some key informants were seen individually whereas other informants (such as former users) were seen in groups.

Do you think drug and alcohol is a problem in your village?

A former Anganwadi worker, Mrs. K, who enjoys good support and respect in the village informed the COC team that drugs and alcohol are the main sources of trouble in the village. She further said that alcohol use is leading to neglect of family and domestic violence. She gave many instances of men folk who had stopped working because of drugs and had forced their wives and young school going children to work. These men would extort money from their family for buying drugs, causing the family members including small children to beg for survival. The children had to stop attending school. She reported her observation, “the boys who were earlier in their pink of health have started looking pale.” The young lads of the village had lost their life's perspective; they are found loitering around in the evenings. She was more concerned about the school going children who have been affected by the drug menace and many of them have dropped out of school.

A former Sarpanch (Mr. S) of the village said that drugs and alcohol have ruined the fabric of the community. He said, “the parents are gradually losing control over their children and the respect for elders from the community is vanishing fast. The village does not have a single instance of professional success, the young boys are fiddling away their precious time for consuming drugs and alcohol.” He also said that - drink till you live, one is not going to carry anything after death- was the attitude of their youngsters. Some of them do not have any motivation to quit and when being requested by the community leaders, say, “do whatever you can; we are not afraid of anything. We would rather go to jail and get free food there.” Mr. S was sad and felt that Dhanas has become the hub of drug abuse!

Dr. D, medical officer, was of the opinion that there is no need of mental health services in the community as there are no instances of mental or substance use disorders in the village.

The multipurpose health workers, when asked about the extent of problems of substance abuse in the community, said, “we are overburdened with our work and though at times we do notice people with these problems, we are not capable of providing them with any help.”

Which are the most common substances abused in the community?

Mrs. K said that alcohol, afeem (form of opium), bhukki (opium husk which is more readily available and is cheaper), charas, smack (street name of heroin), ganja (cannabis), beedi/cigarettes, eraser fluids (solvents), sleeping tablets (benzodiazepines), cough syrups (codeine), capsules (propoxyphene), and injections (buprenorphine); all kinds of drugs are used in the colony. Diphenoxylate tablets are available at a very cheap price and are very commonly used by young lads. She also said that people take injections which are intended for use in cattle to increase their milk production.

Mr. S of the village said, “during my youth only alcohol was available in the colony but now you can get all sorts of drugs in the colony. Since the village is in the outskirts of the city, the accommodation is very cheap and the students coming from the influential families of neighboring states prefer paying guest accommodation here and they have brought novel drugs with them and have ruined the ethos of our village. Also, Chandigarh Transport Corporation has a workshop in the vicinity of the village. The drivers operating inter-state bus services also bring opium from Rajasthan and sell it in the community.”

An opiate addict reported that the elderly men who were earlier taking opium powder have started taking capsules and tablets as they are easier to get and are cheaper.

How severe is the problem? and How is it affecting the community?

Mrs. K and Mr. S informed the COC team that drug addiction is a big problem in their community. Families are finding themselves in helpless situation as the youngsters do not listen to them. After the initial denial, the present Sarpanch now agrees and says, “our village has borne the brunt of rapid growth of the city. Rampant drug abuse in our village is because of rapid migration of unskilled people to the city in search of jobs. People prefer to settle in this village because of lower cost of living than the city. Some of the villagers have converted their houses into paying guest accommodation.” He further admitted, “almost all houses of the village had drug or alcohol abusers, only few houses are left untouched. The chemists sell tablets, capsules, and syrups with addicting potential at an exorbitant price.” Father of an opiate addict reported that “there are only 4–5 houses left in the village which do not have a single drug addict.”

How has the community reacted to drug and alcohol problem?

The village Sarpanch said, “initially the community was seriously concerned about the problem, and it was discussed in many community meetings. The drug users and their families were offered help. In some of the cases, where the patient did not listen to the family, community leaders took the person to the de-addiction centers in and around Chandigarh for treatment. However, the ineffectiveness of treatment and relapse after treatment discouraged the community members and many of them withdrew themselves from making efforts. Since the families failed to convince the person with substance abuse to seek treatment, they were blamed for the problem. Gradually, these families started feeling isolated. These families took out their anger on the person abusing the substance and this resulted in aggression and violence in the community.”

Mr. S and Mrs. K said, “despite the apathy and despair among the community, we tried to gather people to protest, but the chemists denied of selling addictive drugs and the police refused intervening.” Mrs. K narrated another incident where she gathered a group of 60–70 village ladies and sat on a dharna (peaceful protest) in front of the liquor outlet which was opened near the village Gurudwara. They met the health secretary of Chandigarh as well as the assistant district collector and requested the closure of the outlet citing its proximity to the Gurudwara as the reason. The outlet was sealed permanently due to the efforts of the women. Mrs. K said, “other persons from the community feel helpless, but I still bring persons with drug and alcohol problems for treatment in the dispensary. I want to continue my efforts.” She adds, “if I talk to ten persons, at least, one of them listens and this keeps me going.”

Do you think the community needs de-addiction facilities?

Some community leaders felt the dire need of de-addiction facilities in the village. They were grateful to the community team for reaching out to them. Mrs. K said “you people help these half dead persons to gain strength to again stand erect; nothing is nobler than this act of providing treatment to these unfortunate lads.” They felt that availability of de-addiction facility within the village will make it easier to convince those suffering to take treatment. The families who felt abandoned and isolated started seeing hope as other other options had failed. Because of limited resources and lot of time required for seeking treatment from traditional hospital services, they were often not seeking treatment. An opiate user revealed complete ignorance about the provision of treatment and was apprehensive that withdrawals would be life-threatening.

Mr. P, father of one of the opiate users who got well and joined his work after 12 years of regular use said, “I could never imagine that one day my son will be alright. He never discontinued drugs; he ran out from the hospital on two earlier occasions.” This patient now has joined the campaign against drugs and has started bringing his other friends into treatment.


  Discussion Top


The first essential component of primary health care is to educate the people about prevailing health problems and the methods of preventing and controlling them. It is only after community participation and involvement that other type of support activities such as intra- and inter-sectorial coordination, development and mobilization of resources, development of effective referral support and appropriate technology can follow.[8]

Communities welcome the availability of health care services as near to their home as possible. Models for community mental health care, developed by various agencies including nongovernment organization, have shown amazing success which tends to grow over years.[10] Community-based interventions on the drug use problem have also shown good outcomes.[11] Most research reports of such programs have focused on the methodology of their programs and the outcome there of. In most such programs, the prerequisite of community participation is usually met, although such participation may not initially be as broad as desired by the organizers.

Community participation is a mean to increase effectiveness and improve accountability of national and state level health policies. Community participation also serves to raise resources and create infrastructure for various health programs.[12] While it may be difficult to involve the community in health care activities, program functionaries also need to change their outlook toward community involvement. Program functionaries should sensitize and collaborate with affected individuals in a group setting instead of paternalistically directing community members. Such direct and frequent interaction can mobilize community support. Community participation has been postulated to improve community satisfaction and better health outcomes.[13]

In the present scenario, the key leaders of the community (Sarpanch and Medical Officers) were not in synchronization with the needs of their society. Moreover, those who were aware of the problem did not have a significant stake in the decision-making process of their community (former Sarpanch and former Anganwadi worker). The initial denial by the current Sarpanch and acknowledgment by previous Sarpanch may have been for political compulsions. The medical officer's denial of drug use problem in the community is noteworthy. This reflects the need to emphasize psychiatric education in our current medical education system and the training of primary care physician in dealing with mental illness and drug abuse.[14]

Alcohol abuse is often perceived as social problem. The impact of substance abuse on society include increase in un-organized crimes, violence particularly against women, loss of productivity, and the consequent scarcity of monetary resources of the family, accidents under drug influence causing premature deaths and disabilities, and other such effects. Treatment nonseekers often cite the reason for not seeking treatment as “shame” and “ineffectiveness of treatment” as reasons.[9] The efforts of the team which were aimed toward understanding the perceived needs of the village community regarding the problem of substance abuse have helped in activating the community. Our experience can be described in stages which the community passed through to reach the phase of action.

Early hiccups

(i) In the beginning, many patients of substance use disorders reported feeling ashamed of making treatment card in the presence of women of the village at the dispensary. The dispensary is the only health facility in the village which is frequently visited by children and women for health care needs. (ii) Patients also reported difficulty in controlling their urge when they saw others taking drugs in the vicinity. They were even stopped on the way to the dispensary by their friends using drugs. (iii) Easy availability of drugs in the village had amplified their urge to take drugs. (iv) Many patients found it shameful to admit that they have been on drugs as their religion prohibits drug use, for example, “Nirankari Sikh” (this sect forbids the use of any substance of addicting potential).

Denial to acceptance

After a series of meeting with users, their families, and community leaders, the village was seen gradually moving from the early phase of absolute denial to acceptance that drug and alcohol was a serious problem in their village requiring urgent attention. The acceptance primarily came from the pressure of community activists and the families of drug users who impressed upon the village panchayat to admit the ground reality. The village Sarpanch did acknowledge that usage of drugs and alcohol is a serious problem of their village and asserted the panchayat's support to the COC team. He further agreed to discuss it in the monthly village meetings and decided to implement the action plan to be in their village.

Acceptance to action

After consulting the key members of the village and discussion with COC team, the village panchayat decided to initiate the following actions: (i) to carry out a house-to-house survey of the village and prepare a list of drug users experiencing serious problems and motivate them to seek treatment (ii) meeting the families of drug users and extending unconditional support to them (iii) to request the community team to organize a free de-addiction camp in their village (iv) to take the responsibility of arranging funds for the camp (v) to ask the intervention of station house officer in preventing the availability of illicit drugs in their village (vi) to make a group of five youths from the village, educate them regarding the hazards of drug abuse and available treatment. These youths would then meet the affected village youth in groups to educate them. This was essential to address the issue of peer influence on youth.[15] The community was finally joining hands with the team.

Implementation

With growing support from key persons of Dhanas village, the COC team organized de-addiction camp on the occasion of World No Tobacco Day. Village leaders served as catalysts in galvanizing villagers to seek help. The team gradually saw many persons coming for admission into the camp. The panchayat decided to make certain places tobacco free in their village and put warnings for the violators. Further, the gram panchayat felicitated the COC team and Mrs. K on this occasion.

Outcome

The treatment program by the COC has been converted into a regular facility with the active participation of the gram panchayat. After felicitation by the village, Mrs. K increased her efforts in bringing more patients to the dispensary for treatment. Some of them have entered the treatment program for the 1st time and are maintaining abstinence. The persons who achieved abstinence started bringing their friends for treatment. The average number of patients taking treatment in the center has increased as shown in [Table 1].
Table 1: Average number of patients attending de-addiction services at the outreach program

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Numerous reasons have been cited for ineffective community participation. Diverse interest and priorities can be perceived within the community which may be a reflection of social stratification. This social stratification can be political, economic, or religious in nature.[8] Community participation may also be restricted when the health problem in consideration bears significant stigma such as HIV and mental illnesses. Community members may seek remuneration for participation in such programs which may be difficult in the resource-limited situation. Health officials may also be wary of collaborating with villagers for the fear that it may minimize their social status in the community.[16]


  Conclusion Top


Community action interventions take years to be implemented and for changes to be apparent. In the current situation, a thorough understanding of the sociocultural and political ethos of the community helped in chalking out an action plan in which the village leaders were given key responsibilities. The village has prepared itself toward the mobilization of resources and commitment of the volunteers in achieving its goal of a drug-free community. Educating the community and initiation of action has resulted in faith of the community in the COC team.

The next aim of COC is to ensure constant support for the maintenance of community interest and be ready for new challenges as the program moves ahead. At the moment, community is working toward abstinence as an ultimate goal; however, failure to achieve abstinence in many cases might discourage them. The COC has to gear up to face this challenge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Introduction. In: Edwards G, Arif A, editors. Drug Problems in Sociocultural Contexts. A Basic for Policies and Program Planning. Geneva: World Health Organization; 1980. p. 11-9.  Back to cited text no. 1
    
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Mohan D. India: Socioeconomic development and changes in drug use. In: Edwards G, Arif A, editors. Drug Problems in Sociocultural Contexts. A Basic for Policies and Program Planning. Geneva: World Health Organization; 1980. p. 42-7.  Back to cited text no. 2
    
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Mohan D, Sundaram KR, Sharma HK. A study of drug abuse in rural areas of Punjab (India). Drug Alcohol Depend 1986;17:57-66.  Back to cited text no. 3
    
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Prasad R. Alcohol use on the rise in India. Lancet 2009;373:17-8.  Back to cited text no. 4
    
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BBC News – Punjab's Drugs Epidemic. Available from: http://www.bbc.co.uk/news/world-south-asia. [Last accessed on 2010 Dec 08].  Back to cited text no. 6
    
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Basu D, Avasthi A. Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the “Punjab model”). Indian J Psychiatry 2015;57:9-20.  Back to cited text no. 7
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Roy S, Sharma BB. Community participation in primary health care. Health Popul Perspect Issues 1986;9:165-91.  Back to cited text no. 8
    
9.
Pal HR, Yadav S, Joy PS, Mehta S, Ray R. Treatment nonseeking in alcohol users: A community-based study from North India. J Stud Alcohol 2003;64:631-3.  Back to cited text no. 9
    
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Chavan BS, Rozatkar A, Sidana A. Models of community mental health care. In: Chavan BS, Gupta N, Priti A, Sidana A, Jadhav S, editors. Community Mental Health in India. New Delhi: Jaypee Brothers; 2012. p. 269-80.  Back to cited text no. 10
    
11.
Dhawan A, Pattanayak R. Community based addiction psychiatry. In: Chavan BS, Gupta N, Priti A, Sidana A, Jadhav S, editors. Community Mental Health in India. New Delhi: Jaypee Brothers; 2012. p. 195-204.  Back to cited text no. 11
    
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Welschhoff A. Community Participation and Primary Health Care in India [Dissertation]. München: Ludwig-Maximilians-Universität; 2006.  Back to cited text no. 12
    
13.
Kilpatrick S. Multi-level rural community engagement in health. Aust J Rural Health 2009;17:39-44.  Back to cited text no. 13
    
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Chavan BS, Rozatkar AR. Undergraduate psychiatry. In Rao TSS, Tandon A editors. Psychiatry in India: Training and Training centers. Second edition. Mysuru: Indina Psychiatric Society; 2015. p 17-24.  Back to cited text no. 14
    
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Tsering D, Pal R, Dasgupta A. Licit and illicit substance use by adolescent students in eastern India: Prevalence and associated risk factors. J Neurosci Rural Pract 2010;1:76-81.  Back to cited text no. 15
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Kironde S, Kahirimbanyi M. Community participation in primary health care (PHC) programmes: Lessons from tuberculosis treatment delivery in South Africa. Afr Health Sci 2002;2:16-23.  Back to cited text no. 16
    



 
 
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