Substance use disorders among men in urban and rural communities in South Africa: Culture, treatment seeking and service provision

Men of lower socio-economic status in South Africa are more affected by substance use disorders (SUDs), and generally their use of treatment services is very low. Reasons for this are poorly understood but may be due to cultural factors. This study will describe what SUD treatment exists, evaluating barriers which prevent men using treatment services in 2 urban (Khayelitsha, Soshanguve) and 2 rural sites (King Dalindyebo, Madibeng) in South Africa. Specific objectives are to determine the: (1) how SUD treatment services are provided; (2) how demographic, cultural, economic, psychosocial factors and rural-urban migration influence men to seek treatment services; and (3) the burden and severity of SUDs, related common mental health disorders and associated factors.

We will conduct a detailed review of all treatment services in 3 study sites (in Khayelitsha an audit is already completed) providing services to men. One respondent (manager) will be interviewed in each service to collect information required. The influence of culture on how men with SUD seek treatment services will be explored in 32 in-depth interviews (8 per site) and 8 discussion groups (2 per site), and among SUDs treatment service providers in 24 in-depth interviews (6 per site). To determine the burden and severity of SUDs and associated health problems and risk factors, a household survey will be done in Year 2 in the Western Cape, Eastern Cape and North West provinces using random sampling of groups of households, targeting adult men 8 years and above (each N=547). We will also conduct a community survey in Soshanguve using a special sampling method (Respondent Driven Sampling) in Year 3 to estimate prevalence of nyaope use. Recruitment will involve a number of steps until the recommended sample size of 350 users is reached. Study findings will be presented to community stakeholders and key decision makers to propose interventions to improve treatment access.

Substance use disorders (SUDs) disproportionately affect men of lower socio-economic status in South Africa, and treatment uptake is low. Reasons for this are poorly understood. This study examines the nature of SUD treatment provision, and obstacles to treatment-seeking among men in 2 urban (Khayelitsha, Soshanguve) and 2 rural sites (King Dalindyebo, Madibeng) in South Africa. Specific objectives are to determine the: (1) availability and nature of SUD treatment provision; (2) role of demographic, cultural, economic, psychosocial factors and rural-urban migration in treatment-seeking; and (3) prevalence and severity of SUDs, common comorbid psychiatric disorders and associated factors.

We will conduct an audit of all treatment services catering for men with SUDs in three study sites (in Khayelitsha an audit is already completed). In each service one respondent (manager) will be interviewed about the services provided. The role of culture in men's treatment-seeking will be explored via 32 in-depth interviews (8 per site) and 8 focus groups (2 per site) among men with SUDs, and IDIs with 24 SUDs treatment providers. Thematic analysis will identify cultural and other factors affecting treatment seeking dynamics. The prevalence and severity of SUDs and associated comorbidity and risk factors will be assessed via a household survey in Year 2 (in the Western Cape, Eastern Cape and North West provinces) using cluster random sampling, targeting 547 adult men18 years and above. We will also conduct a community survey in Soshanguve using Respondent Driven Sampling in Year 3 to estimate prevalence of nyaope use. Recruitment will involve multiple waves until the recommended sample of 350 users is reached. Findings will be presented to community stakeholders and key decision makers to propose interventions to improve treatment access, informed by all key cultural, economic and psychosocial factors.

This project's focus on cultural factors as an obstacle to access to treatment services for men with substance use disorders (SUDs) will generate new understandings of relevance to the design of services. We will translate these findings through (a) involving key stakeholders as advisors from the outset of the project, which will enable ongoing dialogue; (b) hosting annual public engagements about the findings of the project targeting policy-makers, communities and the research community; (c) targeted engagements with policy-makers in the parliamentary portfolio committee on health; and (d) producing materials that translate the findings into understandable messages directed to communities, civil society and policy makers.

Through dissemination and engagement, we anticipate stronger civil society action and attention to the need for better treatment, and greater responsiveness from policy makers when presented with evidence. The forthcoming National Health Insurance (NHI) Bill in South Africa will provide additional opportunities to ensure that appropriate services are provided within the packages of care in the NHI through the process of public submissions on the Bill.

Lastly, research capacity will be built through research training opportunities on the project for a range of postgraduate students, supervised by experts from participating institutions. The project seminars will share research expertise amongst institutions which will, along with the findings of the project, be incorporated into training programmes in public health across the country, thereby building the capacity of human resources to address the problems of SUDs in South Africa.