Background
Findings from national epidemiological research point to high rates of untreated alcohol and other drug (AOD) use disorders in South Africa [
1]. This is cause for concern as AOD use poses a significant threat to public health in the country. These problems are particularly prevalent in the Western Cape province, with a recent representative survey reporting significantly higher rates for AOD use disorders (20.3%) in this province compared to the national average of 13.3% [
1]. Cape Town, the capital of the Western Cape, is particularly affected by AOD-related problems with this city reporting the highest proportion of alcohol and drug positive arrestees [
2] and emergency room patients [
3] compared to other major cities in the country. Taken together, these findings highlight the need for accessible AOD treatment services in Cape Town.
Despite the demand for AOD treatment in this region, access to treatment is limited in South Africa [
4]. While the limited availability of AOD services restricts access to treatment for all South Africans, treatment is relatively more difficult to access for people from Black African and Coloured (that is people of mixed race ancestry who form a unique cultural group) communities disadvantaged during the course of apartheid who remain under-represented in AOD treatment facilities [
5]. These racial disparities in access to treatment are probably an artifact of the apartheid system of governance. During apartheid, race was a major determinant of access to health and social services (including AOD treatment), with Whites having more access to public services than Coloured or Black African South Africans [
6,
7]. These disparities arose from the legislated geographic segregation of race groups and the distribution of resources along racial lines. This geographical apartheid forced Black African and Coloured South Africans to live in township areas with limited infrastructure that were located considerable distances from the well-resourced urban areas reserved for the use of White South Africans [
6].
Despite 18 years of democracy, South Africa is still grappling with the legacy of apartheid and the challenges of promoting equitable access to public services for all racially-defined social groups. Race remains an important marker of socio-economic advantage in the country which impacts on the extent to which individuals are able to access services [
7]. Poor Black African and Coloured persons continue to experience the most difficulty in accessing health services (including AOD services) relative to other groups [
6,
8]. Only about 16% of South Africans are members of private health insurance schemes (known as medical schemes) and use health services in the private health sector. The remaining 84% of the population, disproportionately represented by poor Black African and Coloured South Africans, are mainly dependent on the overburdened and under-resourced public services sector for access to health care (although some pay out-of-pocket for basic primary care services in the private sector) [
8]. Racial disparities in access to AOD treatment are likely to be entrenched by the limited availability of free AOD treatment services in the public service sector. For example in the Western Cape province, which arguably is among the better resourced provinces in terms of access to AOD treatment services [
4,
5], there are only three AOD outpatient services and three inpatient facilities available in the public service sector that offer free treatment services. The remainder of the AOD inpatient treatment facilities in the province are either private non-profit facilities that offer reduced-cost services but still charge co-payment fees or private for-profit facilities that cater for the proportion of the population with access to medical insurance and charge high fees. Apart from outpatient services offered in the public sector, there are also outpatient services provided by private non-profit treatment providers. Although these agencies provide low-cost services, some do require clients to make a financial contribution towards each appointment. While these AOD services are among the least expensive, these are often unaffordable to poor South Africans, especially when coupled with the costs of travelling to these services.
However, there has been no research on affordability barriers and other factors that may contribute to racial disparities in AOD treatment use. This is worrisome as understanding how barriers and facilitators to AOD treatment entry vary across racial groups is a prerequisite for developing targeted interventions aimed at expanding AOD treatment coverage for underserved groups. This study aimed to redress this gap by identifying differences in barriers and facilitators to AOD treatment use among Black African and Coloured persons from Cape Town, South Africa.
The theoretical basis for this study was the Behavioral Model of Health Services Utilization (BHSU) [
9]. This model was selected because it has been used extensively to examine behavioral health services use, including the use of AOD services [
9‐
11] and also because it explicitly recognises that need for care and psychological and social factors influence access to treatment; factors that are often downplayed in other models of access [
11]. This model adopts a systems approach that integrates a range of individual, contextual and provider variables associated with health services use into a single framework. It allows researchers to examine why individuals use health services, measure equitable access to health services, and guide policy development concerning service use. The model is thought to both predict and explain health service utilisation. Specifically, the BHSU suggests that health service use is a function of the separate and combined influence of predisposing characteristics, factors that enable or restrict health service use, and need variables. Predisposing characteristics (such as demographic and attitudinal-belief variables) exist within a person prior to the onset of a specific health need and predispose a person to use services. Enabling factors represent the person’s actual ability to obtain health services and include affordability factors, geographic accessibility and awareness of services, as well as psychological functioning. Service need variables reflect internal and external perceptions that health problems are severe enough to warrant the use of services [
9,
10].
Discussion
Previous studies have identified racial disparities in the use of AOD treatment services in South Africa, with Black African and Coloured persons consistently under-represented in speciality AOD treatment services [
5,
21]. However there has been a paucity of research examining the factors that underpin these racial disparities. To the best of our knowledge, this study is the first to examine the unique profile of barriers to AOD treatment use among Black African and Coloured persons. As such, findings from this study potentially deepen current understandings of how racial disparities in access to AOD treatment can be ameliorated and service coverage expanded to include these underserved populations. More specifically, the study found several similarities and differences in terms of the profile of treatment barriers experienced by Black African and Coloured AOD-using persons.
First, findings suggest that key structural barriers to accessing AOD treatment are common among people disadvantaged during the apartheid regime, irrespective of race group membership. More specifically, geographic access barriers (related to length of time taken to travel to the nearest treatment facility) and affordability barriers were significantly associated with not accessing AOD treatment for both Black African and Coloured participants. These findings are not altogether surprising given that several studies have noted similar structural barriers to accessing public health services in post-apartheid South Africa for Black African and Coloured South Africans [
6,
8,
22]. Although these key barriers were reported by Black African and Coloured persons, variations in the extent to which these barriers impact on the probability of AOD treatment use were noted.
Specifically Black African persons appear more susceptible to the effects of geographic access barriers than Coloured persons. This may be the result of the enduring spatial inequalities that exist between race groups in the country. During apartheid both Black African and Coloured South Africans were forced to reside in areas that were geographically removed from urban hubs, however apartheid planning ensured that Black African communities were relatively further removed from these well-resourced urban centres and had relatively less infrastructure than Coloured communities [
6,
8]. This increased the distance and time required to travel to the nearest treatment facility. Unfortunately, this spatial segregation did not stop with the end of apartheid, with post-apartheid low-cost housing developments for Black African communities who previously had little access to social housing still located far from the urban periphery [
23]. In addition, these areas are poorly served by public transport, with Black African populations having significantly less access to public transport services than Coloured populations [
23]. Together these factors most likely underpin Black African persons’ increased vulnerability to geographic access barriers through increasing the distance, time and difficulty in travelling to the nearest AOD treatment facility.
These findings suggest several strategies for improving access to AOD treatment for Black African and Coloured persons (although Black African persons may benefit most from interventions to reduce geographic barriers to treatment entry). First, careful consideration should be given to the positioning of new AOD treatment services and how these services are delivered. If new services are located far from Black African communities they will entrench geographic access barriers for this population. In addition to building new facilities close to underserved communities, another strategy would be to introduce mobile outpatient AOD services into underserved communities. Not only would mobile services improve treatment availability, but they would reduce Black African persons’ travel time (and concomitant costs) to the nearest AOD service. As mobile services have never been used for the delivery of AOD services in South Africa, future research should consider piloting a mobile AOD service to test whether this mode of service delivery is feasible to implement and acceptable to the target population.
In addition, findings suggest that affordability barriers are somewhat stronger determinants of AOD treatment access for poor Coloured persons compared to their Black African counterparts. This finding is counterintuitive given evidence that Black African communities experience more financial barriers to accessing health services than Coloured communities [
9,
23]. This surprising finding does not mean that affordability barriers are not significant determinants of AOD treatment access for Black African persons. A closer examination of the data shows that Black African persons who had never accessed treatment reported significantly more affordability concerns compared to their Coloured counterparts. It is possible that the relatively homogenous responses of Black African participants on the affordability barriers scale compared to Coloured participants may have reduced the possibility of detecting any measurable association between these barrier variables and access for this population subgroup in multivariate analyses. Regardless of the reason for these differences, findings point to the importance of reducing treatment costs as a means to improve AOD treatment use for both Black African and Coloured communities. In South Africa, AOD treatment services are only offered by stand-alone treatment facilities. There are few free AOD treatment services available and most not-for -profit services require user co-payment fees [
21]. One strategy for expanding the availability of free AOD services to poor South African communities would be to initiate AOD intervention services within the country’s free primary health care and social service systems. As these primary health and social services are located within easy reach of underserved communities, the provision of AOD services within these settings would alleviate the financial burden of user co-payment fees while also reducing geographic barriers to AOD treatment access.
A shared facilitator to AOD treatment entry for Black African and Coloured persons is awareness of where to go for AOD treatment, with the likelihood of AOD treatment use improving with every increase in the number of known treatment facilities. This suggests that access for underserved groups could be improved by increasing public awareness of where and how to access AOD treatment. However, we found differences in the degree to which Black African and Coloured persons were vulnerable to the influence of this variable, with Black Africans relatively more susceptible to the effects of awareness on access than Coloured persons. This could be because of poor health literacy around AOD-related problems and addiction in Black African communities relative to Coloured communities. In recent years, Coloured communities have been the target of several AOD awareness campaigns whereas Black African communities have been relatively neglected due to the perceived low prevalence of AOD problems in these communities [
24].
One promising avenue for improving awareness of AOD services (and subsequently treatment use) among Black African communities lies in the important role that relationships with others play in Black African communities. Black African communities have a collectivist cultural orientation that emphasises relatedness to and interdependence with others [
25,
26]. In comparison, Coloured communities are not as collectivist in cultural orientation and place less emphasis on relatedness to others [
25]. Within Black African communities, this emphasis on social and community relatedness impacts on the use of health services; with evidence of social networks in these communities buffering people against the effects of limited awareness and poor health literacy on service use [
26,
27]. Awareness-related interventions targeted at the level of the social network thus may be an effective strategy for improving access to AOD treatment in Black African communities. This study’s finding of considerably greater odds of accessing treatment among Black African participants for whom significant others had suggested the need for AOD treatment (compared to those for whom significant others had not) provides support for the potential role that social networks can play in facilitating treatment access in Black African communities. Community health workers (that is health workers without formal health care training who function to promote community health, provide preventive services, and address barriers to health care [
28]) are ideally placed to conduct community outreach to improve awareness of AOD treatment and to provide support for families and social networks dealing with AOD problems. With a little investment in training, this cadre of health worker could also help identify and encourage people with AOD problems to seek services.
Further distinctions in the profile of factors associated with AOD treatment use among Black African and Coloured persons were found. Perceived need for treatment (as assessed by the question do you think you need treatment) and the SOCRATES “taking steps to change” scale were associated with AOD treatment entry for Black African participants only. These findings show that Black African participants are most likely to enter treatment when they have a strong perceived need for treatment and are already taking steps to change their AOD use. In contrast, these variables were not associated with access to AOD treatment for Coloured participants, suggesting that Coloured persons are able to access treatment regardless of their degree of problem recognition or readiness to change. These findings imply that Black African persons enter AOD treatment at a later point than Coloured persons, when their AOD problems are apparent and they identify the importance of change. This may be a result of greater difficulties in accessing AOD treatment relative to their Coloured counterparts.
A further variation between Black African and Coloured AOD treatment seekers was that perceived stigma was significantly (and positively) associated with AOD treatment use among Coloured participants only. This finding of a positive association between stigma and treatment use is surprising given previous research which notes that stigma hinders rather than promotes entry into AOD treatment [
29]. One possible explanation for this unexpected finding lies in this study’s measurement of perceived stigma. This study employed the stigma consciousness scale which measures perceptions of being judged negatively on the basis of one’s AOD use rather than on the basis of one’s use of AOD treatment services [
20]. It is quite possible that high levels of stigma around problematic AOD use cause such distress that people enter treatment partly to alleviate this distress. Earlier qualitative research which reported that people from disadvantaged communities experience stigma in relation to their problematic AOD use rather than their use of AOD services [
30] provides some support for this explanation. Further, this qualitative research pointed to the intense stigma associated with the problematic use of methamphetamine. As methamphetamine-related problems are significantly more prevalent among Coloured relative to Black African communities [
5], this may help explain why perceived stigma was such a salient facilitator of AOD treatment entry for Coloured participants but not for Black African participants.
Findings from this study should be considered in the light of several limitations. As a case-control design precludes a temporal examination of the factors associated with treatment utilization, inferences about causality cannot be made. Further, the use of a matched design ruled out an examination of race differences in the likelihood of AOD treatment use. Third, the crude conceptualisation of access employed by this study prevented an examination of whether there were differences between participants who had unsuccessfully attempted and those who had never attempted to access services. Fourth, strict selection criteria may have reduced the variability of the sample and impacted on the extent to which many predisposing variables were associated with treatment entry. Finally, as this study was limited to adults from disadvantaged communities in Cape Town, the extent to which findings are representative of more rural or other urban regions in South Africa is questionable. Yet as the Western Cape is one of the best resourced provinces in terms of AOD services [
21], it is highly likely that these barriers are even more salient elsewhere in the country.
These limitations highlight the need for further research on AOD treatment use in South Africa. Future research should include longitudinal prospective studies that track people with AOD-related difficulties and allow researchers to unpack the factors that precipitate entry into AOD treatment utilization for each race group. These longitudinal studies will also allow researchers to monitor racial disparities in accessing treatment and evaluate the impact of interventions to reduce these disparities. To address concerns about the external validity of findings, studies on factors associated with AOD treatment use in other parts of the country (particularly rural regions) and for other population subgroups (such as adolescents) are required. In addition, researchers should conduct experimental intervention studies that test whether study recommendations for improving access to AOD treatment among poor Black African and Coloured South Africans impact positively on AOD treatment use.
Competing interests
The author declares she has no competing interests.