Background
In South Africa, the prevalence of substance use disorders is high [
1,
2], with the lifetime and past year prevalence of substance use disorders among adults being 13.3% and 5.8%, respectively [
1]. Among these 12-month prevalent cases, approximately 30.9% have a severe substance use disorder and therefore are likely to benefit from treatment [
1]. Epidemiological studies suggest that substance use disorders are concentrated in the Western Cape Province [
2]. In this province, the lifetime prevalence of substance use disorders among the general population is significantly higher (20.3%) and problem severity greater than the national average [
1]; suggesting a considerable need for substance use treatment services in this province. The widespread use of methamphetamine among people who use drugs in the Western Cape [
2‐
4] is a likely contributing factor to the severity of substance use disorders in this province, as people who use methamphetamine are significantly more likely to report worse health and social problems than people who use other substances [
5,
6].
Even though evidence-based treatment programs are available in the Western Cape [
7], only a small proportion of people with substance use disorders in this province ever receive treatment [
8,
9]. Women from disadvantaged communities are significantly less likely than men to obtain treatment for these disorders, even when the severity of their drug problems is comparable [
5,
10]. While systemic and structural barriers to accessing treatment have been identified among women from impoverished communities in the Western Cape [
11,
12], these barriers do not fully account for why poor substance-using women fail to utilize available services. Failure to perceive a need for treatment, a key determinant of health services use [
13] and a necessary step in the process of changing addictive behaviors [
14], may contribute to the poor uptake of treatment for substance use disorders by vulnerable women. Perceived need for treatment is often low among people with substance use disorders [
15], including poor South African women [
9,
16,
17]. One study reported that only 39.8% of women who met DSM-IV criteria for a current substance use disorder perceived a need for treatment [
17]. As people who perceive a need for treatment are more likely to initiate treatment and have better substance use outcomes than those who do not think treatment is necessary [
15,
18‐
20], helping substance-using women recognize a need for treatment may be an important focus for interventions directed at improving treatment initiation among disadvantaged women.
Nationally representative surveys of substance use in the United States (US) have identified correlates of perceived need for treatment that deepen our understanding of the characteristics of people who may benefit from interventions to improve perceived need for treatment. These studies found that socio-demographic factors such ethnicity (not white) [
15,
21,
22], marital status (being unmarried) [
15,
21,
23], age (being older) [
21], and education (higher education) [
24] were associated with increased odds of perceiving a need for treatment. In addition, having a poorer physical [
21,
23] and mental health status [
15,
21‐
23], greater alcohol [
15,
22] and drug use [
15,
18] problem severity, greater functional and social impairment [
18,
23] and more emotional support [
24] increased the likelihood of perceiving a need for treatment. People with stimulant use disorders were also more likely to perceive a need for treatment than people with other types of substance use disorders [
15]. Finally, prior substance use treatment and having a family history of substance use disorders has also been positively associated with perceived need for substance use treatment [
15,
18,
22].
While these studies provide insights into factors associated with perceived need for substance use treatment in the US, it is unclear whether these correlates are relevant for low- and middle-income countries, such as South Africa. Furthermore, research on this topic has largely examined correlates of perceived need for treatment among populations undifferentiated by gender, with no studies investigating factors associated with perceived need for treatment among women specifically. These knowledge gaps are cause for concern as they limit our ability to identify women who may benefit most from interventions that enhance perceived need for substance use treatment.
As a first step to addressing this gap, we explored the correlates of perceived need for substance use treatment among young, drug-using women from Cape Town, South Africa. The Behavioral Model of Health Services Utilization (BHSU) [
13] was the theoretical basis for the study and guided variable selection. Although the BHSU was originally developed to understand health services utilization [
8,
13], it has also been used to predict perceived service need [
25,
26]. According to the BHSU, perceived need is a function of the separate and combined influence of predisposing factors (e.g. demographic, attitudinal-belief variables), enabling conditions that encourage the person to perceive a need for services (e.g. income, relationship status, awareness of services, and social support), and health needs (e.g. physical and mental health status and functional impairment) [
13,
25,
26]. Using this framework, this study aimed to identify the profile of variables associated with perceived need for treatment among young substance-using women from disadvantaged communities in Cape Town, South Africa. As methamphetamine use is highly prevalent among young women from these communities [
3,
4] and because people who use methamphetamine report greater physical and mental health problems and less social support relative to people who use other types of substances [
3‐
6], we hypothesized that there might be differences in the pattern of correlates associated with perceived need for treatment among young women with and without recent methamphetamine use. As a result, we also compared and contrasted the profile of variables associated with perceived need for treatment among young women with and without recent methamphetamine use.
Discussion
This study is among the first to explore factors associated with perceived need for treatment among young, substance-using women in a low- and middle-income country. Unlike US studies that indicate only 11% to 15% of individuals who should obtain substance use treatment are likely to perceive a need for treatment [
15,
19‐
22], 46% of participants in this study conveyed a need for substance use treatment. This considerably higher level of perceived need for treatment is probably because all participants were enrolled in an integrated substance use and HIV risk reduction intervention and as a result may have been motivated to address their drug use. Nonetheless, a considerable proportion of participants with substance use problems did not think they needed treatment. As perceived need is a critical step in help-seeking for substance use disorders [
12,
13,
20] and because it is necessary for positive treatment outcomes [
18‐
20], these findings suggest that a substantial proportion of substance-using women from disadvantaged communities in Cape Town, South Africa may possibly benefit from brief interventions that build readiness to change and enhance perceived need for treatment.
In keeping with earlier studies [
14,
20‐
22] and with the BHSU theoretical framework [
13], various health need variables were associated with perceived need for treatment among young women. Psychological distress increased the likelihood of young women conveying the need for substance use treatment. However, when the sample was stratified by methamphetamine use, psychological distress was only significantly associated with perceived need for treatment among participants who tested negative for methamphetamine use. Similarly poor physical health was only significantly associated with perceived need for treatment among participants with recent methamphetamine use. These findings were unexpected as participants who tested positive for methamphetamine had significantly more symptoms of depression and anxiety and were more likely to report poorer physical health than participants without recent methamphetamine use. These findings are in keeping with a large body of research which has demonstrated that people who use methamphetamine have poorer physical and mental health outcomes relative to people who use other types of drugs [
4,
6,
18,
37,
38]. Among the enabling variables, income was significantly (albeit weakly) associated with perceived need for treatment for the overall sample, with the likelihood of recognizing a need for treatment increasing as income decreased. This is probably because income is a proxy indicator for socioeconomic stability [
17,
39] and socioeconomic instability related to substance use may lead to help-seeking [
17,
39]. Yet when the sample was stratified by methamphetamine use, this variable was only associated with treatment need among participants who tested negative for methamphetamine. These findings suggest that, at least for women without recent methamphetamine use, brief interventions to enhance perceived need for drug treatment should educate women about the negative health and socioeconomic consequences of continued drug use and how treatment can improve psychosocial functioning. Such interventions could potentially enhance women’s perceived need for treatment, although this hypothesis requires testing in a randomized controlled trial.
There are several possible explanations for why these health need and socioeconomic factors were not associated with perceived need for treatment among methamphetamine-positive women. First, it is possible that women who use methamphetamine interpret symptoms of mental illness and physical ill-health as short-term consequences of methamphetamine intoxication and withdrawal, and therefore might not find these symptoms as distressing or as compelling to address as women who use other drugs. Another possibility is that they may feel that methamphetamine helps them with cope with life stressors and psychiatric problems [
30], thereby discounting the need for treatment. Third, the neurocognitive effects of methamphetamine [
40] may limit women’s insight into how methamphetamine impairs psychosocial functioning. This in turn may negatively influence decision-making about the need for substance use treatment [
39]. Regardless of the reason for these findings, our failure to find variables associated with perceived need for treatment among women who use methamphetamine point to the need for additional research in this population. In particular, qualitative research is needed to deepen our comprehension of the factors associated with perceived need for drug treatment among young women who use methamphetamine and how physical and mental health status impact on perceived need for drug treatment in the context of methamphetamine use. In addition, quantitative research is needed to explore whether cognitive deficits among methamphetamine users impact on perceptions of functional psychosocial impairment and perceived need for treatment.
In addition, having family members with drug problems decreased the likelihood of perceiving a need for treatment among the overall sample. Having family members with drug problems might normalize drug use within the family system, thereby diminishing individuals’ awareness of their own problematic drug use [
39] and reducing the likelihood that family members will encourage and support help seeking for drug use [
41]. As previous studies have noted that a lack of emotional and tangible social support for treatment-seeking impacts negatively on treatment initiation [
11,
30,
42], interventions that provide women with emotional support for changing their drug use and tangible support (such as assisting with childcare and providing transport to appointments) could potentially address barriers to treatment entry [
11] and enhance women’s perceived need for drug treatment, although this hypothesis requires testing.
Finally, a large proportion of our sample recognized that they needed treatment, indicating substantial unmet treatment need among young women from disadvantaged communities in Cape Town. Almost all of these participants wanted to go to treatment, with the majority willing to enter treatment within the next 30 days. However, close to half the sample were unaware of where they could obtain treatment. As awareness of treatment programs was associated with perceived need for treatment among women who were methamphetamine-negative, treatment programs should consider ways in which they can improve their visibility within disadvantaged communities. Programs that conduct community-based outreach and screening to identify women who perceive a need for drug treatment and to link them to care may be helpful in addressing this treatment gap.
To successfully link young substance-using women to treatment, more work needs to be done to ensure that available services are a good fit for this underserved population. In this study, prior treatment for a substance use disorder was not significantly associated with perceived need for treatment, even though this variable has been consistently associated with need for treatment in the USA [
15,
18,
22]. This suggests that young women who had previously obtained treatment may not have experienced prior treatment as sufficiently helpful to perceive a need for these services again, despite returning to substance use. This is not surprising as earlier research has shown that women from disadvantaged communities in Cape Town have some concerns about the appropriateness and effectiveness of substance use treatment that limit treatment seeking [
11,
12]. Efforts to link young substance-using women to treatment therefore should engage young substance-using women in discussions about their treatment and other service needs and perceptions of what constitutes acceptable and appropriate treatment. Information generated from these discussions may guide treatment providers on how to improve the fit of their services for young women.
Interpretation of these findings should however be considered in the light of some limitations. First, this paper was based on baseline data from a larger substance use and HIV risk reduction study. The strict inclusion and exclusion criteria of this randomized field experiment may have biased our ability to recruit a representative sample of substance-using women from poor communities in Cape Town. Our sample is likely biased towards women who do perceive their drug use to be problematic as some women who were eligible for this study declined to enroll as they did not see the need for an intervention. While this bias might have led to an over-reporting of perceived need for treatment, the main aim of this study was to examine correlates of perceived need rather than assess the prevalence of perceived need for treatment among this underserved population. Related to this, our choice of variables for these analyses was limited to those included in the larger experiment. As such, we were unable to explore potential associations between substance use severity, functional impairment and social support on perceived need for drug treatment. Future studies should consider including a broader range of covariates, including covariates that may be specific to the experiences of women such as number of dependent children, availability of child care and quality of relationship with partner. Third, as the sample was recruited from poor communities within Cape Town, the extent to which findings can be generalized to other parts of the province or country is unclear. Finally, the cross-sectional nature of the data makes it difficult to disentangle whether psychological distress and socioeconomic factors preceded or followed problematic substance use. Either could impact perceptions of need for treatment. To address this limitation, future research should consider prospective designs that enable researchers to unpack the temporal associations between variables associated with perceived need for treatment and explore whether perceived need for treatment predicts treatment initiation. These prospective studies will also be able to shed light on the temporal stability of perceived need for treatment, an area that has been under-researched.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BM was a co-investigator on the study and was responsible for planning the paper, conducting the analyses and writing and reviewing all aspects of the manuscript. TLK and IAD assisted with the statistical analyses and writing the methods and results. WMW, TC and TLK and IAD reviewed the draft manuscript and provided critical comments and approved the final draft. WMW is the principal investigator for this project and senior author on this paper. She takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final manuscript.