153J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 153–157 Research Perceived Stigma and Treatment-Seeking Behavior in Individuals with Substance Use Disorder in Baghdad Qahtan Q. Mohammed Department of Psychiatric Mental Health Nursing, College of Nursing, Baghdad University, Iraq. Correspondence to Qahtan Q. Mohammed (email: qahtan_82@yahoo.com). (Submitted: 3 September 2016 – Revised version received: 29 September 2016 – Accepted: 8 October 2016 – Published online: 26 December 2016) Objectives The present study aims at assessing the treatment-seeking behavior and perceived stigma among individuals with substance use disorder in Baghdad; identifying the impact of perceived stigma upon treatment-seeking behavior; and determining the relationship between perceived stigma and socio-demographic characteristics of substance abusers. Methods A descriptive, analytical study was established for the period from January to August, 2016. The study was conducted on a purposive sample of (50) substance abusers who are attending Substance Abuse Rehabilitation Centers at a teaching hospital in Baghdad. The instrument of the study is adopted and modified for the purpose of this study. Two scales were used in this study which is the Treatment Needs and Motivation Scale (TCU MOTForm), and Perceived Stigma of Substance Abuse Scale (PSAS). A self-administered report was applied as a mean of data collection. The data were analyzed through the application of descriptive and inferential statistical approaches which are applied by using IBM/SPSS Package version 20.0. Results The results of the present study showed that substance abusers were single (52%) with age ranged between 20–29 years old (54%), with barely sufficient monthly income (48%), and they do not work (40%). 72% of them were living in a high class neighborhood and they were substances abuser for more than two years duration (80%). The individuals with substance use disorder are showing a fair level of treatment-seeking behavior and they perceived moderate level of stigma. There is no significant impact of the stigma and socio- demographic upon the treatment-seeking behavior. And also, there is no significant relationship between perceived stigma and socio- demographic characteristics of individuals with substance use disorder. Conclusions The study concluded that perceived stigma among substance abusers has no impact upon their treatment-seeking behavior, and also, perceived stigma among substance abusers is insignificantly correlated with their socio-demographic variables. Keywords perceived stigma, treatment-seeking behavior, substance use disorder Introduction Substance use disorder is an important issue in the mental health aspect that is associated with many social problems such as poverty, crime situations, risky behaviors and stigma- tization.1 The Global Status Report on Alcohol and Health by the World Health organization (2011) recognized alcohol as a major contributing factor to disease, death, and injury.2 By reason that substance use induction and maintenance is regu- larly viewed under the control of the person, the individuals with substance use disorder are more probable to be blamed for their condition. So, substance use disorder is associated with significant stigma.1 Stigma is defined as “a mark signifying deviancy and by the presence of a deeply discrediting attribute”.3 Stigma can be reported in a socio-cultural process in which specific groups in the society are undervalued, rejected and discriminated.4 Stigma can be assumed at different levels, which are personal, social, and structural level.5 The personal level is viewed by perceived self stigma,6 the social level is viewed by the expres- sion of stereotype and prejudice by the public towards indi- vidual with particular health conditions,7 and the structural level is viewed by the seclusion of a particular group at the level of economic and political policies.8 Treatment seeking behavior can be defined by the indi- viduals’ behavior for getting appropriate treatment that they perceive themselves as having health problems.9 Treatment seeking behavior can be used as an indicator of an individual’s readiness to maintain life, and is important to personal, public and social development.10 The utilization of health care ser- vices can be reported as a type of individuals’ behavior that is elucidated in term of individual-environment interaction.11 As a result of cultural and socioeconomic differences in term of illness perception, treatment- seeking behavior can be affected by cultural beliefs about the illness.10 Choosing the treatment source can be affected by different factors such as services accessibility, type and severity of illness, and individual socio-demographic characteristics.12 A stigma has been reported as one of the major barriers to treatment seeking among a scope of psychiatric disorders.13 Substance use disorder is one of these psychiatric disorders that affect a significant portion of the population. Due to asso- ciated social and economic problems with substance use dis- order, substance users are reported with significant stigma that may differ from other health problems.14 Stigma towards indi- vidual with substance use disorder provokes social alienation and has an impact on multiple domains of life, such as employ- ment status, housing, and social relationships. So, the outcome of stigma for individuals with substance use disorder encom- passes poor mental and physical health, delayed treatment seeking and non-adherence to treatment.5 While there is increasing evidence for documenting the damaging effects of mental illness stigma on psychological wellbeing, few studies have been shown on examining the effects of stigma in specific psychiatric disorders such as the stigma towards substance use disorder that has been studied rarely. However, the stigmas towards substance use disorder showing various negative consequences on substance users.3 In this paper, the researcher is trying to predict the impact of stigma upon treatment seeking behavior among substance ISSN 2413-0516 154 J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 153–157 Perceived stigma and treatment- seeking behavior in individuals Research Qahtan Q. Mohammed users in which considered as one of the significant barriers that affect on treatment seeking phenomenon. Materials and Methods Design of the study: A descriptive, analytical study was car- ried out for the period from January to August, 2016, in which assessment technique was used and applied in order to achieve the objectives of the current study. Sample of the study: The study conducted on a purposive (non-probability) sample of 50 clients with substance use disorder. Setting of the study: The study was conducted on the individuals with substance use disorder who are attending Substance Abuse Rehabilitation Centers at teaching hospital in Baghdad, which are Ibn-Rushd Psychiatric Teaching Hospitals and Baghdad Teaching Hospital. The administrative arrange- ment for conducting the present study has been obtained from Ministry of Health /Al- Rusafa Health Directorate/Ibn-Rushd Psychiatric Teaching Hospital and Medical City Directorate/ Baghdad Teaching Hospital. The consent facilitated the research- er’s entrance into the centers, meeting the clients and obtaining the agreement of them to participate in the present study. Eth- ical consideration has been granted by the Ethical Committee for Research/ College of Nursing- University of Baghdad after reviewing the content of the questionnaire. Instrument of the study: The study scales were adopted and modified by the researcher; two scales were used in this study; the first scale was Treatment Needs and Motivation (TCU MOTForm),15 and the second scale was Perceived Stigma of Substance Abuse Scale (PSAS). 16 The questionnaire of the study was consisted of four parts: the first part was the cov- ering letters for obtaining the agreement to participate in the study, the second part was the socio-demographic characteris- tics of the clients, the third part was (TCU MOTForm), and the fourth part was (PSAS). Three domains of TCU MOT- Form scale were selected in order to measure the treatment seeking behavior, which are consisted of (22) items which are rated into five - Likert scale and scored as follows: 1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, and 5 = strongly agree. The levels of treatment-seeking behavior were estimated by calculating the cut off points for the total score of the scale, which are rated in three levels and scored as follows: poor = 22–51, fair = 52–81, and good = 82–110. The PSAS scale was used to measure the stigma, the scale consists of (8) items. These items were rated in five -Likert scale. The items scored as follows: 1 = strongly disagree, 2 = agree, 3 = neutral, 4 = agree, and 5 = strongly agree, the items 1, 2, 3, 4, 6, and 8 are reversely coded. The levels of stigma were estimated by calculating the cut off points for the total score of the scale as follows: mild = 8–18, moderate = 19–29, and severe = 30–40. Data collection: A self-administered report was applied as a mean of data collection. The questionnaire was distributed to the clients after being willing to answer the questionnaire and participate in the study. The time consumed for filling the questionnaire was approximately 20–35 minutes. Statistical analysis: The data were analyzed through the application of descriptive and inferential statistical approaches which are applied by using IBM/SPSS Package version 20.0. The statistical procedures that are used for analyzing the data were: frequencies, percentages, mean of the score, cutoff point, linear simple regression, and correlation coefficient. Results This table indicated that more than half of the sample were single (52%) with age ranged between 20 and 29 years old (54%), 48% of them reported barely sufficient monthly income, and they do not work (40%). 72% of them were living in a high-class neighborhood, and they were substances abuser for more than 2 years duration (80%). This table revealed that individuals with substance use disorder are showing a fair level of treatment-seeking behavior (64%). This table shows that individuals with substance use dis- order perceive moderate level of stigma (80%). The analysis of simple linear regression revealed that the stigma and socio-demographic characteristics have no impact on the treatment-seeking behavior in individuals with sub- stance use disorders at p-value ≤ 0.05. This table showed that there is no significant relationship between perceived stigma and socio-demographic character- istics of individuals with substance use disorder. Discussion The analysis of the socio-demographic in Table 1 reveals that substance users were single, 20–29 years old with barely suffi- cient monthly income, who doesn’t work. And living in a high class neighborhood and they are using substances for more than two years duration. The prevalence of substance use dis- order at the age range of 20–29 years old who are single can be explained that this category is more prone to the peer pressure, which is considered as the most important factor among youth; youth have the readiness to learn certain behavior, therefore peer pressure is a potent factor in the initiation of substance use at this age group. In addition to the peer pres- sure factor, the experimentation, circumstantial situations and recreation also play an important role in the prevalence of sub- stance use in this age group and social status. A study pre- sented to support evidence for this result that found Lamptey17 who found that substance use disorder is prevalent among unmarried youth with age group 20–29 years old. Regarding monthly income and occupational status results, it can be inferred that substance use disorder is more prevalent in people who doesn’t work which are usually associated with moderate to low income; with one hand, they can’t work and get a job due to the effects of substances that they are used. On the other hand, as a result of their jobless status, they will be associated with low income due to the cost of getting these substances. SAMSA18 reported that the current illicit drug use differed by employment status. It is also reported that the rate of drug use was higher for unemployed person that for those who were employed.19 Milson et al.20 have found that alcohol and drug abuse were common among persons with lower income than the person with a higher income. Regarding the findings of residence and duration of substance uses, the explanation of such findings can be presented in the factor of residence; it has been known that most of the clients were living in high class neighborhoods which are usually open- minded. According to our culture, there is difference among people who are living in a different neighborhood. Usually, high class neighborhood is characterized by social openness in which individuals may experiment substance uses, such as alcohol in the local public occasions. A study presented Qahtan Q. Mohammed 155J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 153–157 Research Perceived stigma and treatment- seeking behavior in individuals usually has negative attitudes toward substance in term of immoral behaviors; violent, aggressive, and criminal behav- iors are usually associated with those abusers. So, they are stig- matized by the public, this stigmatization is understood by discrimination towards them, which have led to perceiving self- stigma among them. Many studies have presented sup- porting evidence to this finding that found moderate to high level of stigma was associated with substance use disorder.23–25 The analysis of Table 4 reveals that the stigma and socio- demographic characteristics have no impact on the treat- ment-seeking behavior in individuals with substance use disor- ders. The current findings were coming against the hypothesis of the researcher. The explanation of such finding is that substance abusers are highly motivated to treatment, therefore, their feeling of shame and stigma are less, considering that substance use dis- order is less severe than other mental illness. On the other hand, another reason should be considered in finding that such is the coping level that have adopted by those substance abusers that depends on their consciousness of the problem. The current finding was inconsistent with many studies8,26,27 who reported Table 1. Characteristics of the individual with substance use disorder No. Characteristics F % 1 Age group: ≤ 19 years 6 12 20–29 year 27 54 30–39 year 13 26 40–49 year 1 2 50 ≤ year 3 6 Total 50 100 2 Marital status: Single 26 52 Married 18 36 Divorced 3 6 Widowed 3 6 Total 50 100 3 Monthly income: Insufficient 12 24 Barely sufficient 24 48 Sufficient 14 28 Total 50 100 4 Occupation: Doesn’t work 20 40 Retired 3 6 Employer 11 22 Free works 16 32 Total 50 100 5 Residence: High class neighborhood 36 72 Low class neighborhood 14 28 Total 50 100 6 Duration of substance use: Less than 2 years 10 20 More than 2 years 40 80 Total 50 100 No, Number; F, Frequency; %, Percentage. supportive evidence that found Al-Zaiady21 who found similar results. Table 2 reveals that individuals with substance use disorder are showing a fair level of treatment-seeking behavior. Such findings may be explained that individual with substance abuse have the moderate motivation for the treatments. Many factors play an important role in seeking the treatment among sub- stance abusers; the most important are family and social factors. However, health and treatment seeking is influenced by the social stigma of the population towards substance abusers, therefore, most of them seeking treatment only when they aware of the symptom severity that they experiencing as a result of prolonged substance abuse. A study presented supportive evi- dence for this result that found Goteborg22 in his study. The analysis of findings regarding the perceived stigma of substance use disorder Table 3, it shows that substance abusers having a moderate level of stigma. Substance use disorder is considered as less severe than mental illness, in which the cli- ents are able to take an action in their treatment of themselves, however, the stigma is usually reported by those who are undergoing for the treatment of substance abusing. The public Table 2. Treatment-seeking behavior among individuals with substance use disorder Levels of Behavior F % M.S Poor (22–51)* 2 4 2.28 Fair (52–81)* 32 64 Good (82–110)* 16 32 Total 50 100 No, Number; F, Frequency; %, Percentage; MS, Mean of score; *, Cutoff point. Table 3. Perceived stigma in individuals with substance use disorder Levels of Stigma F % M.S Mild (8–18)* 6 12 1.86 Moderate (19–29)* 40 80 Severe (30–40)* 4 8 Total 50 100 No, Number; F, Frequency; %, Percentage; MS, Mean of score; *, Cutoff point. Table 4. The impact of stigma and socio-demographic char- acteristics upon treatment- seeking behavior among individuals with substance use disorder (N = 50) Independent Variable Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta Stigma 0.093 0.381 0.039 0.245 0.808 Age –1.827 2.805 –0.140 –0.651 0.518 Marital status 2.212 2.433 0.185 0.909 0.369 Monthly income 2.027 2.915 0.120 0.695 0.491 Occupation 0.465 1.318 0.055 0.352 0.726 Residence 4.139 4.862 0.152 0.851 0.400 Duration of Substance use –2.806 5.081 –0.092 –0.552 0.584 Dependant variable: Treatment-Seeking behavior; B, Beta; Std, Standard; t, statistical test; Sig, Significance. 156 J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 153–157 Perceived stigma and treatment- seeking behavior in individuals Research Qahtan Q. Mohammed Table 5. The relationship between perceived stigma and socio-demographic characteristics of the individual with substance use disorder (N = 50) Correlation Age Marital status Monthly income Occupation Residence Duration of Substance use Stigma Age 1.00 - - - - - - Marital status 0.673** 1.00 - - - - - Monthly income –0.051 0.015 1.00 - - - - Occupation 0.192 0.161 0.171 1.00 - - - Residence –0.097 0.040 0.522** 0.282* 1.00 - - Duration of Substance use 0.407** 0.304* 0.028 –0.014 –0.134 1.00 - Stigma 0.038 –0.168 –0.185 0.067 –0.121 –0.164 1.00 **, Correlation is significant at the 0.01 level (2-tailed); *, Correlation is significant at the 0.05 level (2-tailed). that stigma has negative consequences on consuming health services and is a main barrier for treatment seeking. Despite of perceived stigma is a relatively understudied construct in the addictive research articles; more attention has been received from the research community in recent years. So, there is significant evidence that supports the notion that substance abusers experience stigma and are negatively affected by its consequences.28,29 Surprisingly and contradic- tory to prior preliminary results, our findings Table 5 suggest that there is no significant relationships among perceived stigma and socio- demographic characteristics of substance abusers. The explanation of insignificant relationships between the stigma and the variable can be summarized depending on the descriptive analysis of the socio-demographic characteristics for substance abusers. Single youth abusers may view their disorders as a general medical condition; especially they have no social responsibilities. Most of the clients with substance abuse disorder are conscious enough about their disorder; they usually express their regret for their situation and the negative consequences that they get. The substance abusers are aware of their jobless and low socioeconomic status. For the reasons above, they may perceive stigma moderately that is insignificant related to their socio- demographic characteristics. A study presented supportive evidence for this result that found Mattoo et al.5 that was found inverted significant relationship in his study. Conclusions 1. Substance abusers have self-awareness for seeking treat- ment for their disorder presented in their treatment-seeking behavior. 2. The stigma is moderately perceived by substance abusers. 3. Perceived stigma among substance abusers has no impact on their treatment-seeking behavior. 4. Perceived stigma among substance abusers is insignifi- cantly correlated with their socio-demographic variables. Recommendations 1. Awareness program should be conducted through the media and sessions about treatment and negative conse- quences of substance use disorder. 2. 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