Negative attributions towards people with substance use disorders in South Africa: Variation across substances and by gender

Substance use represents a major public health problem, both globally and in South Africa. Results from the South African Stress and Health Study (SASH), the first nationally-representative study of psychiatric morbidity in South Africa indicate a high lifetime prevalence (13.3 %) and early onset (21 years) of substance use disorders [1]. Despite this high prevalence, only 27.6 % of South Africans who met the criteria for a substance use disorder received treatment in the year preceding the interview [2].

A few studies have attempted to investigate barriers to accessing treatment for substance use. For example, a lack of available services or structural barriers [3] and a low perceived need for treatment [4] are often cited as significant barriers to accessing substance abuse services. Previous research has also identified stigma towards people who use drugs as a barrier to treatment entry, with individuals who need help tending to deny or hide their condition for fear of being negatively labelled [5].

Substance use disorders are highly stigmatised, with several studies reporting that these disorders are more stigmatised than other physical [6‐8] and mental disorders [9‐12]. For example, a cross-national study conducted by the World Health Organization (WHO) that examined 18 of the most stigmatised conditions (e.g., being a criminal, HIV positive, or homeless), ranked alcohol addiction as the fourth most stigmatised condition, while drug addiction was ranked as the most stigmatised condition [13]. Additionally, although persons with psychotic disorders are often viewed as dangerous and unpredictable, substance use disorders appear to elicit more stigmatising reactions than schizophrenia [14, 15]. For example, drug addiction was rated higher than 6 other mental disorders on dimensions of dangerousness to others, being difficult to talk to, and unpredictability [14].

Although there is some research available examining attitudes and attributions towards people who use varying classes of drugs [16‐19], none have been conducted in a low and middle income country (LMIC). While studies conducted in high income countries generally found that the use of “harder” drugs such as cocaine was rated more negatively than “softer” drugs such as alcohol or cannabis, it is unclear whether these findings are relevant or can be extrapolated to a LMIC such as South Africa where the profile of drug use is very different and where problematic drinking is one of the single greatest threats to public health [20].

Although a few South African studies have investigated the stigma associated with alcohol use compared to other mental disorders [10, 11], there are no data available on the stigma associated with illicit drug use In addition, these previous studies did not examine whether the attributions made about people who used substances varied according to the type of substance being used. A better understanding of the type of attributions made towards South Africans who use substances may be valuable for the development of interventions to reduce stigma and thereby address an important barrier to substance abuse treatment use in the country [5].

Another limitation of previous South African research is the failure to examine whether publicly-held attitudes towards women who use substances differ from those held towards men. As several studies have found that women who use drugs experience high levels of perceived and enacted stigma [21], it is quite likely that attitudes towards women who use drugs are more stigmatizing than those towards men. If this is the case, this could partially explain why women with substance use disorders from disadvantaged communities in South Africa do not access treatment services as readily as men [22]. However, as previous studies have not examined differences in attitudes towards substance abusing men and women, this explanation remains unsupported by research. This lack of data impedes the development of targeted interventions to address this potentially important barrier to substance abuse treatment entry for women.

The present study is a response to these gaps in earlier research on stigma and substance use. Specifically, this paper aims to examine attributions made by the general South African population about people who use substances and whether these attributions differ by the type of substance being used, the gender of the person using the substance, or the characteristics of the person making the attribution.

This study, the first of its kind to examine public stigma towards people who use substances in South Africa, had four important findings. First, high levels of public stigma were reported for all classes of substances investigated in this study. Specifically, the average scores on the AQ-9 for the various classes of substances ranged from 4.8-6.2 (well above the neutral score of 4.5); indicating that people who use substances are viewed negatively by the general population. Furthermore, as these AQ-9 scores are higher than those obtained for depression (4.7), schizophrenia (4.9), panic disorder and PTSD (4.9) by a previous study that used similar methods and was conducted in a similar location [10], these findings suggest that the South African public view people who use substances in a more negative light than persons with other mental disorders. Although it is plausible that between-study factors could have partially accounted for this difference, this finding is in keeping with results from previous studies conducted in other contexts [12, 14, 15]. One explanation for this difference may lie in attributions of personal culpability that are more often made about people with substance-related problems compared to people with other mental disorders, especially when these mental disorders are viewed as having structural causes [25, 26]. These findings suggest that in order to reduce the high levels of stigma towards people who use substances, public mental health literacy programmes need to be expanded to include better information about substance use disorders. For example, accurate information about the neurobiological roots of substance use and other mental disorders may help challenge attributions about personal responsibility for substance use disorders. Given our findings of low levels of mental health literacy relating to substance use disorders, this may be a powerful intervention for reducing stigma towards people who use substances [27].

Second, all the characters in the vignettes were viewed equally negatively by the respondents regardless of the type of substance being used; with the exception of the cannabis user who was considered significantly less “dangerous” than someone who uses alcohol. These findings are inconsistent with previous studies conducted in developed country settings that found the use of “harder” drugs (such as methamphetamine or heroin) to be rated more negatively than the use of “softer” drugs such as alcohol and cannabis [28, 29]. One explanation for why respondents may have viewed people with alcohol problems as equally as dangerous as people who use “harder” drugs may lie in the high prevalence of problem drinking in South Africa [1, 20] and the large burden that alcohol places on communities in terms of alcohol-related injuries, alcohol-related violence and alcohol-related crime [30].

The third important finding is that publicly held attitudes towards women who used substances differed from those held towards men. Although attributions of pity, dangerous, blame, anger and segregation did not differ between men and women, vignettes of women who used cannabis and methamphetamine evoked more negative attributions from respondents (namely avoidance and coercion in treatment) than vignettes of men who used these substances. This is not altogether surprising given previous research in South Africa and elsewhere which has noted that women with substance use disorders are perceived more negatively than men [5, 21]. This may be because women’s drug use is strongly associated with perceived inability to fulfil traditional gender roles, such as taking care of dependent children [31] and also because methamphetamine use, in particular, is strongly associated with discourses of female sexual availability and “immoral” behaviour [5] which goes against widely held beliefs about appropriate (conservative) female sexual conduct in a predominantly patriarchal country [32]. In contrast, the vignettes of women who used alcohol evoked positive responses (of offers to help) compared to those for men, which evoked responses of coercion into treatment. This finding is inconsistent with earlier studies, conducted in developed country settings, which reported high levels of stigma towards women with alcohol-related problems [33]. While the reasons for this unexpected finding are not clear, one potential explanation may lie in public perceptions that women’s drinking is less associated with adverse social consequences (such as crime and violence) than men’s drinking [34]. Nonetheless, this explanation requires further investigation through qualitative research that unpacks the reasons why the public perceives men with alcohol-related problems in a more negative light compared to their female counterparts.

Finally, it appears that people who use substances more frequently held differing attitudes towards people with substance use disorders than those who reported using substances less often. Although attributions of pity, dangerous, blame, anger and segregation did not differ between users and non-users, respondents with higher substance use involvement scores were less likely to offer “help” and more likely to report wanting to “avoid” the characters in the vignettes than respondents with low substance use involvement scores. In a similar vein, respondents who had received previous substance abuse treatment were more likely to “blame” the individuals in the vignette for their substance use than those who had never received treatment. These findings may be explained by previous research examining self-image bias in drug use attributions which found that people who use substances were more likely than non-users to make stable, less controlled and more dispositional attributions about their own use and other’s use of substances [35]. It is argued that substance users often rationalize their own behaviour by adopting an “addicted” explanation of substance use, minimizing personal responsibility for their behaviour [36]. These findings may also reflect community norms which distinguish between people with unproblematic substance use and those who have developed substance use disorders; with the latter being viewed as “mad, “bad”, and having “lost control” [5]. These norms may result in people who use substances wanting to distance themselves from individuals with substance use problems. These possible explanations however require further investigation.

These four findings should be considered in the light of some limitations. First, these data are based on self-report and are therefore subject to the limitations of self-report bias. Second, responses may have been influenced by social desirability, thus leading to an underestimation of stigma levels. Third, because of convenience sampling, the results may not be generalizable to the broader South African population, although we did try to ensure that the sample was broadly representative of the socio-demographic composition of the population in the Western Cape Province where the study occurred. Related to this, although fieldworkers randomly approached people to participate in the study, they may have inadvertently self-selected participants to approach, hence biasing the sample. Finally, the vignettes used to elicit attitudes may provide only a partial picture of the disorder. Reading a description of an individual’s symptoms may not directly relate to one’s ability to recognize symptoms of psychopathology. Similarly, a self-report describes one beliefs about what one would do when confronted with a particular situation, but it does not describe what one actually does in that situation.

This study revealed high levels of public stigma across all classes of substances, the cannabis user was considered significantly less dangerous than someone who uses alcohol, there were gender differences in attitudes towards people who use substances, and the more an individual used substances the more likely they were to hold a negative attitude. These findings highlight the importance of developing targeted interventions specifically for the South African context. Interventions designed to strengthen mental health literacy and gender-focused anti-stigma campaigns have the potential to increase treatment seeking behaviour.