|Year : 2016 | Volume
| Issue : 1 | Page : 42-45
Preferences for treatment setting by substance users in India
Anju Dhawan, Anita Chopra, Rajat Ray
Department of Psychiatry and National Drug Dependence Treatment Centre, AIIMS, New Delhi, India
|Date of Web Publication||28-Jan-2016|
National Drug Dependence Treatment Centre, AIIMS, Ansari Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Drug and alcohol use is a growing public health concern for India. Treatment services delivery for substance use disorders is available through three sectors viz. Government (GO) centres under Ministry of Health and FW, Non-Government (NGO) under Ministry of Social Justice and Empowerment and the private sector. Information on ttreatment utilisation and preferences of treatment settings by substance users are not available for India. Methods: A performa was filled up prospectively for each consecutive new patient seeking treatment for drug/alcohol use (excluding tobacco) at De-addiction centres funded by MOH&FW; NGOs under MoSJE and private psychiatrists between 15 th July to 15 th October, 2011. All data available for 182 drug using persons from private, 1228 persons from 35 NGOs and 1700 persons from GO organizations were entered into SPSS-21.0, data quality checks performed and analysed. Results: There was a variance in the population profile in the three sectors providing treatment delivery for substance users in India. Treatment seeking for illicit drugs (heroin, opiates and cannabis) was higher in GO sector; injection drug use was higher in NGO sector while alcohol was higher in private sector. Conclusions: Strengthening linkages between GO and NGO sector is important for an improved coverage and quality of treatment services in the country. The Andersen's Behavioural Model as theoretical background to clarify some issues in analyzing with larger datasets is warranted.
Keywords: Substance use, Networking, Treatment setting preferences, Nongovernmental organization, India
|How to cite this article:|
Dhawan A, Chopra A, Ray R. Preferences for treatment setting by substance users in India. Indian J Psychol Med 2016;38:42-5
|How to cite this URL:|
Dhawan A, Chopra A, Ray R. Preferences for treatment setting by substance users in India. Indian J Psychol Med [serial online] 2016 [cited 2020 Jan 20];38:42-5. Available from: http://www.ijpm.info/text.asp?2016/38/1/42/175105
| Introduction|| |
Drug and alcohol use is an area of growing concern for India. The 2004 National Household survey  prevalence estimates extrapolate to approximately 130.1 million alcohol users; 18.6 million cannabis users and about 4.3 million opiate users as per 2011 census (as no national survey was undertaken after this survey). As per same calculation, the number of dependent users is also quite large with approximately 21.8 million alcohol users; 4.7 million cannabis users and about 0.95 million opiate users constituting the treatment load. Currently, there are three types of sectors involved in treatment delivery for substance use disorders in India. In the Government (GO) sector, Ministry of Health and Family Welfare (MoH and FW) has set-up 122 de-addiction centers for the treatment of drug/alcohol abuse/dependence. The centers are located in Medical Colleges and Civil/District Hospital in different states in the country. In the Non-Government (NGO) sector, there are about 400 NGOs funded by the Ministry of Social Justice and Empowerment (MoSJE) for treatment and rehabilitation of users. The third key player is the private sector where several persons seek help for their substance use and related problems though no official statistics or data are available from this sector.
The demand for treatment seeking by persons for their substance use remains a persistent challenge for addiction services. There is a considerable delay in treatment seeking,  and patients are selective of healthcare care giver  and often move from one to another. Research reports state enabling, predisposing, and need factors influencing the decision to use health services. No data of people preferences for substance use treatment settings are available for India. Under a MoH and FW and World Health Organization (I) collaborative program (2010-11), an exercise was conducted to gather information on inter-sectoral referral gathered through information on organization profile, zonal meetings, and data of treatment seekers in the three sectors. This brief communication reports on the preferences in the choice of the sector by substance users seeking treatment.
| Methods|| |
Data were collected for new treatment seekers at GO de-addiction centers using a 19-item proforma.  This performa was sent to 122 centers funded by MOH and FW; 8 Regional Resource And Training Centres under MoSJE which further sent it to the NGOs monitored by them, and private psychiatrists were contacted through the President of the Indian Association of Private psychiatrists. All were requested to fill up the proforma prospectively for each consecutive new patient seeking treatment for drug/alcohol use (excluding tobacco) presenting to them from July 15 to October 15, 2011. This specific period of 3 months was linked to the time-frame of the activity. All data were entered using Statistical Package for Social Sciences (SPSS) IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. (SPSS Inc., 2010), data quality checks performed and examined. Finally, data were available for 182 drug-using persons from 4 private psychiatrists, 1228 persons from 35 NGOs, and 1700 persons from 25 GO organizations.
Profile of substance users
As can be seen from [Table 1], certain differences in the profile of substance users were noted between the three sectors. Though no differences on age and sex of person seeking treatment were seen, significant differences in marital status (P < 0.001) were observed. The unmarried (34.6%) were higher in private sector, currently married in GO sector (65.5%), and married but single status (separated/divorced or separated due to drug use) in NGO sector (10.8%). The educational level varied in the three sectors (P < 0.001). Illiterates/literates were higher in the GO (14.1%); 8-12 years of schooling was reported by 56% in private and 66.3% in NGO sector. In the private sector, 33% reported being a graduate/postgraduate which was much higher than the GO (8.9%) and NGO sector (10.5%). Students were higher in private (5.0%) sector. The unemployed were higher in NGO (31.8%) compared to GO (28.7%) and private (23.5%) sector. Though majority were staying with family, however in NGO sector, persons living with friends were higher compared to other sectors.
The query on the primary drug for which treatment was being sought revealed that the choice of sector differed for different substances [Table 2]. Treatment seeking for illicit drugs (heroin, opiates and cannabis) was higher in GO sector; injection drug use (IDU) was higher in NGO sector while alcohol was higher in the private sector.
| Discussion|| |
The study looked at preferences in treatment seeking by substance users between GO, NGO, and private sectors in India. A variance in the population profile in the three sectors was observed. The treatment seekers' profiles showed some commonalities and differences. The mean ages were similar across the sectors (35 years) and most were males and married. However, persons with higher education status and students presented to the private sector while persons with low education status and unemployed were higher in the GO and NGO sectors. This is not surprising as preferences for health service utilization by individual predisposing factors such as age, religion, education, and enabling factors like income and wealth ,, have been found to influence people's health care-seeking behavior.
The setting of choice for primary drug for which treatment was being sought also differed. Treatment seeking for illicit drug use was higher in GO sector; injection use in NGO; alcohol and sedative/hypnotics use in the private sector. Women were under-represented in accessing treatment services in all sectors. Findings suggested a higher rate of treatment demand for alcohol use disorders followed by opioids (largely heroin) being the dominant drug (illicit) and some cannabis users also accounted for treatment demand.  From the study findings, it emerged that the GO settings are meeting treatment needs of illicit drug users. Health care utilization reportedly is influenced by organizational factors which entail structure and processes of the health care systems where trust, , user fees,  time, distance, waiting time, acreage,  and affordability have been mentioned. The governmental sector is generally recognized as the first option and people trust public providers for their clinical skills, referral system, and honest interactions with patients. 
It has also been noted that the poor interpersonal relationships in GO sector act as access barrier, pushing people to seek care from private providers.  There is a common perception that the private sector will offer better service  (although more expensive), continuity of care, availability of same clinician each time, and personalized attention and are visited by choice. As there was a low response from the private sector in the present study, it is difficult to speculate on reasons for choice. Though care for IDUs supported by National AIDS Control Organization (NACO), GO of India (NACO) is available both at the GO and NGO centers, in present study, the injection drug users were largely accessing services from NGO settings which are probably perceived as more client centered  as also their visibility in the community setting is high.
Researchers report that for-profit treatment facilities are less likely to serve poorer clients and offer key ancillary/transitional services than nonprofits.  For India, the GO and NGO sector appear to be serving an important part in increasing access to treatment for the poor and providing the extent of treatment services required by the vulnerable drug-using population. The GO sector is an important treatment provider, and the NGO sector has the flexibility and access to most vulnerable population at the community level. Strengthening linkages between these two sectors is important for improved coverage and quality of treatment services in the country. Further increasing community awareness on the availability of addiction treatment services in GO/NGO sector is important as such information increases the probability of visiting a health provider. 
A future direction of substance abuse treatment will be when the GO sector contracts with NGO sector for networking treatment and key ancillary/transitional services and not sees themselves as separate tracks? To rectify this, a directory of services for GO and NGO providers with details on the availability of addiction treatment services in these sectors needs to be in place. There is a need to design a health services information campaign for updating the users and general population about appropriate and relevant information on availability and range of treatment services in GO/NGO settings.
The study is bound by a limitation as the data are not fully representative of the three sectors due to differences in the participation rates. No complex statistical methods were used, and the explanatory limited to single indicators. Nevertheless, this preliminary analysis suggests on differences in preferences of treatment sectors. Future research is needed that uses the Andersen's behavioral model  as theoretical background to clarify these issues in analyzing utilization behavior and preferences of treatment settings with larger datasets and additional variables to see whether the present findings endure.
The study was conducted with funds received from the World Health Organisation Representative to India Office under Biennium programme 2010-11/bearing grant No. SE/11/127944. The authors wish to thank our study partners for their support in the conduct of the study.
Financial support and sponsorship
WHO (India office), Ministry of Health and FW under Biennium Programme.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ray R, editor. The Extent, Pattern and Trends of Drug Abuse in India, National Survey. Ministry of Social Justice and Empowerment and United Nations Office on Drugs and Crime, Regional Office for South Asia; 2004. Available from: www.unodc.org/pdf/india/publications/south_Asia_Regional_Profile_Sept_2005/10_india.pdf [Last accessed on 2015 Jul 8].
ten Have M, de Graaf R, van Dorsselaer S, Beekman A. Lifetime treatment contact and delay in treatment seeking after first onset of a mental disorder. Psychiatr Serv 2013;64:981-9.
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review. PLoS Med 2012;9:e1001244.
Ray R, Chopra A. Monitoring of substance abuse in India - Initiatives & experiences. Indian J Med Res 2012;135:806-8.
Rani M, Bonu S. Rural Indian women's care-seeking behavior and choice of provider for gynecological symptoms. Stud Fam Plann 2003;34:173-85.
Yanagisawa S, Mey V, Wakai S. Comparison of health-seeking behaviour between poor and better-off people after health sector reform in Cambodia. Public Health 2004;118:21-30.
Nuwaha F. Determinants of choosing public or private health care among patients with sexually transmitted infections in Uganda. Sex Transm Dis 2006;33:422-7.
UNODC. World Drug Report 2013 (United Nations publication, Sales No. E.13.XI.6); 2013. p. 10.
Russell S. Treatment-seeking behaviour in urban Sri Lanka: Trusting the state, trusting private providers. Soc Sci Med 2005;61:1396-407.
Ozawa S, Walker DG. Comparison of trust in public vs private health care providers in rural Cambodia. Health Policy Plan 2011;26 Suppl 1:i20-9.
Muriithi MK. The determinants of health-seeking behavior in a Nairobi slum, Kenya. Eur Sci J 2013;9:1857-7881.
Amaghionyeodiwe LA. Determinants of the choice of health care provider in Nigeria. Health Care Manag Sci 2008;11:215-27.
Thara R, Patel V. Role of non-governmental organizations in mental health in India. Indian J Psychiatry 2010;52 Suppl 1:S389-95.
McBride DC, Chriqui JF, Terry-McElrath YM, Mulatu MS. Drug treatment program ownership, Medicaid acceptance, and service provision. J Subst Abuse Treat 2012;42:116-24.
Thompson R, Miller N, Witter S. Health-seeking behaviour and rural/urban variation in Kazakhstan. Health Econ 2003;12:553-64.
Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: A systematic review of studies from 1998-2011. Psychosoc Med 2012;9:Doc11.
[Table 1], [Table 2]