University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA EXPLORING SUBSTANCE ABUSE AND SUBSTANCE USE DISORDERS IN PATIENTS RECEIVING TREATMENT AT ANKAFUL PSYCHIATRIC HOSPITAL. BY AYAWA BIOVA DOUMON (10334899) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MSC IN APPLIED HEALTH SOCIAL SCIENCE DEGREE. JULY, 2022 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Ayawa Biova Doumon, declare that part of this research where investigations from other researchers were used have been properly acknowledged. This paper is my independent study done under the supervision of Dr. Faustina Hayford Blankson. I declare to the best of my knowledge; that this research has not been offered by anyone for any academic award in this or other Universities. 15/07/2022 ……………………………. ………………….. Ayawa Biova Doumon Date (Student) 15/07/2022 …………………………… …………………… Dr. Faustina Hayford Blankson Date (Supervisor) i University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I hereby certify that this dissertation was presented and supervised by the procedures laid down by the University of Ghana. 15/07/2022 ………………………… … ………………………. Ayawa Biova Doumon Date (Student) 15/07/2022 ……………………………. ……………………….. Dr. Faustina Hayford Blankson Date (Supervisor) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to the almighty God for taking me through this program successfully and to my beloved brother NUTIFAFA YAO DOUMON (Ph.D.) for his guidance, financial support, and prayers. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS This dissertation was supported by important people whose help, guidance, and support cannot be overlooked. Firstly, I am grateful to my supervisor, Dr. FAUSTINA HAYFORD BLANKSON for her guidance, involvement, and coaching throughout the entire study. Her contributions to my work, level of support, encouragement, and counsel were exceptional. Secondly, my gratitude goes to Dr. Tabong for his readiness to always answer my queries. My appreciation goes to all the teaching and non-teaching staff of the Department of Behavioral and Social Sciences, School of Public Health, and the staff of Ankaful Psychiatric Hospital, for their unfailing support. Thirdly, I am grateful to Emmanuel Tetteh, Etsey David Akpakli, Stephen Aguadze, Lydia Sekyebea Larbi, Mawuli Sevor, and Seth Kudzro for their contributions and support. Last but not the least; I am grateful for the emotional support extended to me by my sister, my younger brother, my parents, and all my friends. iv University of Ghana http://ugspace.ug.edu.gh Table of Contents DECLARATION ................................................................................................................. i CERTIFICATION .............................................................................................................. ii DEDICATION ................................................................................................................... iii ACKNOWLEDGEMENTS ............................................................................................... iv LIST OF TABLES ............................................................................................................. ix LIST OF FIGURES ............................................................................................................ x LIST OF ACRONYMS ..................................................................................................... xi DEFINITION OF TERMS ................................................................................................. x ABSTRACT ....................................................................................................................... xi CHAPTER ONE ................................................................................................................. 1 INTRODUCTION .............................................................................................................. 1 1.0 Summary ................................................................................................................... 1 1.1 Background of the Study ........................................................................................... 1 1.2 Problem Statement .................................................................................................... 4 1.3 Research Questions ................................................................................................... 8 1.4 Objectives of the Study ............................................................................................. 8 1.4.1 General Objective ............................................................................................... 8 1.4.2 Specific Objectives ............................................................................................. 8 1.5 Relevance of the Study .......................................................................................... 9 1.5.1 Policy ................................................................................................................ 10 1.5.2 Practice ............................................................................................................. 10 1.6 Conceptual Framework of Substance Abuse .......................................................... 12 Narration of conceptual framework .............................................................................. 13 CHAPTER TWO .............................................................................................................. 16 LITERATURE REVIEW ................................................................................................. 16 2.0 Introduction ............................................................................................................. 16 2.1 Classification of Substances .................................................................................... 16 2.1.1 Narcotics or Opioids ......................................................................................... 16 2.1.2 Stimulants ......................................................................................................... 17 2.1.3 Depressants ....................................................................................................... 17 2.1.4 Hallucinogens ................................................................................................... 18 2.1.5 Marijuana or Cannabis ...................................................................................... 18 v University of Ghana http://ugspace.ug.edu.gh 2.1.6 Steroids ............................................................................................................. 19 2.1.7 Inhalants............................................................................................................ 19 2.2 Theoretical Framework ........................................................................................... 20 2.3 Substance Abuse and its related SUDs, a Public Health Concern .......................... 22 2.4 Factors Associated with Substance Abuse and its Related Disorders ..................... 24 2.4.1 Influence of Socio-Demographic and Economic Characteristics of Substance Abuse ......................................................................................................................... 24 2.4.2 Influence of Genetic Predispositions ................................................................ 27 2.4.3 Lack of Knowledge of the Real Effects of Substances (no perceived risk) ..... 27 2.4.4 Accessibility of Drugs ...................................................................................... 28 2.4.5 Psychological factors ........................................................................................ 29 2.4.6 Home Environment........................................................................................... 33 2.5 Social Support and Social Network ........................................................................ 37 2.5.1 Peer Pressure..................................................................................................... 37 2.5.2 Social Acceptance, Media Portrayal, and Marketing of Substances ................ 38 2.6 Summary of Literature ............................................................................................ 39 CHAPTER THREE .......................................................................................................... 41 METHODOLOGY ........................................................................................................... 41 3.0 Introduction ............................................................................................................. 41 3.1 Study Design ........................................................................................................... 41 3.2 Study Site ................................................................................................................ 42 3.3 Study Population ..................................................................................................... 43 3.4 Inclusion and Exclusion Criteria ............................................................................. 43 3.4.1 Inclusion Criteria .............................................................................................. 43 3.4.2 Exclusion Criteria ............................................................................................. 43 3.5 Sample Size Determination ..................................................................................... 43 3.6 Purposive Selection of Participants ......................................................................... 44 3.7 Data Collection Tools.............................................................................................. 45 3.8 Data Collection Procedure ...................................................................................... 45 3.9 Data Processing and Analysis ................................................................................. 46 3.10 Quality Assurance ................................................................................................. 47 3.11 Limitation of the Study ......................................................................................... 48 3.12 Ethical Consideration ............................................................................................ 48 vi University of Ghana http://ugspace.ug.edu.gh 3.13 Compensation ........................................................................................................ 50 3.14 Funding Information ............................................................................................. 51 CHAPTER FOUR ............................................................................................................. 52 RESULTS ......................................................................................................................... 52 4.0 Introduction ............................................................................................................. 52 4.1 Background Characteristics of Participants ............................................................ 52 4.2 Commonly Abused Substances among SUD Patients of Ankaful Psychiatric Hospital ......................................................................................................................... 53 4.3 Distribution of Substance Use Disorders Diagnosed among SUD Patients of AnPH ....................................................................................................................................... 53 4.4 Alcohol-Induced Psychosis ..................................................................................... 54 4.4.1 Cannabis-Induced Psychosis ............................................................................ 54 4.4.2 Nicotine Use Disorder ...................................................................................... 55 4.4.3 Opioids Use Disorder ....................................................................................... 55 4.4.5 Polysubstance Psychosis................................................................................... 55 4.5 Factors Influencing Substance Abuse and SUDs .................................................... 56 4.5.1 Curiosity (New experiment) ............................................................................. 56 4.5.2 Easy Accessibility............................................................................................. 57 4.5.3 Enhancement of Learning and Academic Performance ................................... 59 4.5.4 Lack of Awareness (No Perceived Risk of Substance Abuse) ......................... 60 4.5.5 Negative Home Environment ........................................................................... 61 4.5.6 Psychological Issues ......................................................................................... 64 4.5.7 Peer Pressure..................................................................................................... 65 4.5.8 Social Acceptance and Media Marketing ......................................................... 67 4.6 Challenges Faced by Patients Suffering from SUD ................................................ 68 4.6.1 Emotional Reactions ......................................................................................... 68 4.6.2 Stereotyping and Discrimination ...................................................................... 69 4.6.3 Exclusion from major decisions ....................................................................... 71 4.6.4 Loss of Respect and Social Status .................................................................... 72 4.6.5 Academic and Career Disruptions .................................................................... 73 4.6.6 Financial difficulties ......................................................................................... 74 CHAPTER FIVE .............................................................................................................. 76 DISCUSSION ................................................................................................................... 76 vii University of Ghana http://ugspace.ug.edu.gh 5.0 Introduction ............................................................................................................. 76 5.1 Commonly Substances Abused and related to SUD ............................................... 76 5.2 Factors Influencing Substance Abuse ..................................................................... 78 5.3 Challenges Faced by SUD Patients ......................................................................... 82 CHAPTER SIX ................................................................................................................. 84 SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS ............ 84 6.0 Summary of Findings .............................................................................................. 84 6.1 Conclusion ............................................................................................................... 85 6.2 Recommendations ................................................................................................... 85 6.2.1 Law enforcement by Policy-Makers and Various Stakeholders ...................... 85 6.2.2 Liaison Between Scientific Experts and Policymakers .................................... 86 6.2.3 Future Research ................................................................................................ 86 REFERENCE .................................................................................................................... 88 APPENDIX A: INTERVIEW GUIDE ........................................................................... 102 APPENDIX B: CONSENT FORM ................................................................................ 105 APPENDIX D: GHANA HEALTH SERVICE ETHICAL CLEARANCE .................. 107 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Distribution of substance use disorders diagnosed among the SUD patients ..... 54 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1 Conceptual Frame Work .................................................................................. 12 x University of Ghana http://ugspace.ug.edu.gh LIST OF ACRONYMS AOD Alcohol and Other Drugs AnPH Ankaful Psychiatric Hospital FDG Focus Group Discussions IDI In-Depth Interviews NACOB Narcotics Control Board NIDA National Institute of Drug Abuse NSDUH National Survey on Drug Use and Health SAMHSA Substance Abuse and Mental Health Services Administration SUD Substance Use Disorder xi University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Illicit drugs: category of medicines that are unlawful to manufacture, sell, or consume. It is also a group of medications that are lawful to manufacture, sell, and consume only when prescribed by a doctor. Polydrug use: Any use of more than one mood-altering drug by an individual at any time in the past. Prescription drugs: known as licit drugs are medicines that can only be gotten with a doctor's prescription Substance: is any of such as cigarettes, illegal drugs, prescription drugs, inhalants and solvents Substance abuse: a long-term, pathological use of alcohol, prescription drugs, and illicit drugs marked by everyday drunkenness, inability to reduce consumption, and impairment in social or vocational functioning Substance use disorder: known as drug addiction, is an illness that affects a person's brain and behavior, resulting in an inability to manage the use of any drug or prescription, whether legal or illicit. x University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Substance use disorders (SUDs) became one of the major public health issues in Ghana and constitute one of the leading causes of preventable deaths. The abuse of alcohol, prescription, and illicit drugs can be outlined among many youths and adults across Ghana. The complexity of global substance abuse leading to substance use disorders is driven by so many factors. Considering the incessant cases of SUDs, it is imperative to understand the factors influencing these behaviors among youths and adults in Ghana. Therefore, this study explored commonly abused drugs in Ghana, the sociodemographic characteristics influencing substance abuse, factors associated with substance abuse, and the challenges faced by patients suffering from SUDs at Ankaful Psychiatric Hospital. Methods: The research used a descriptive study design. The population of this study was comprised of all patients who have been diagnosed with substance use disorders in Ankaful Psychiatric Hospital, a purposive sampling method was used in recruiting the participants. A qualitative research approach was employed in this research. Data were collected using in-depth interviews and focus group discussions. Data were then analyzed using a thematic content analysis approach. Results: Findings of this study showed that most drugs abused by participants are alcohol, cigarettes, cannabis, tramadol, amphetamine, cocaine, heroin, and pethidine. It was also observed that out of various disorders diagnosed among the participants, cannabis-induced psychosis is the prevalent substance use disorder. The various factors which influenced substance abuse and SUDs identified in the participants identified were curiosity, lack of awareness of the negative effects of substances, ease of accessibility of substances, enhancement of learning and academic xi University of Ghana http://ugspace.ug.edu.gh performance, negative home environment, psychological factors, peer pressure, social acceptance and media marketing of substances. The challenges faced by participants were academic disruption, emotional reactions, loss of respect, loss of social status, financial difficulties, stereotyping, discrimination, and societal blame. Benefits: This study will help enrich knowledge on substance abuse in Ghana. It will help lawmakers not only concentrate on scientific advances but also consider the social factors influencing substance abuse to generate better policies for the citizens of Ghana. xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Summary The study sought to explore the common substances abused by patients suffering from substance use disorders before their diagnosis. Specifically, the research is an exploratory study that explored factors influencing substance abuse in both patients with mild or severe SUDs, highlighting similarities and differences in factors that influences the abuse of substance in both mild and severe SUD patients. It also explored the challenges faced by patients ever since their abuse started having negative effects on their lives. This chapter covers the study background, problem statement, research objectives, research questions, the significance of the study, 1.1 Background of the Study Major concerns arise in the sector of public health, in which substance abuse and its related disorders have become one of the leading issues (Lo et al., 2020). Drug abuse and its detrimental repercussions, which range from psychiatric to criminal, continue to be a major threat to human survival and growth. While drug misuse is a global issue that transcends age and gender, different studies around the world have discovered distinct demographic differences in this issue (Olurishe, 2019). Cadri et al (2021) stated that a survey conducted in Ghana reported that, 1.25 million Ghanaians struggle with drug abuse, with marijuana being the most common drug identified among cocaine, heroin, methamphetamines, and other synthetic opioids including tramadol and codeine (Cadri, Nagumsi, et al., 2021). In the case of tramadol for example the first instance of non-medical tramadol usage in Ghana was recorded in 2016, which caused the government to declare it a prohibited substance, making it unlawful to purchase or sell 1 University of Ghana http://ugspace.ug.edu.gh tramadol without a prescription. After a pause, non-medical tramadol use has persisted among Ghana's lower-income population (Appiah et al., 2018). Another research conducted by Cadri et al (2021) noted that drug usage and the frequency of diseases associated with drug use were both increasing in the Sunyani Municipality, stating that 26 percent (596) of 2284 patients who used the mental health institution within the municipality were instances related to alcohol and drugs. The Diagnostic and Statistical Manual of Mental Disorders (DSM)'s fifth edition merges the DSM-IV categories of drug abuse and substance dependence into a single illness (substance use disorder), which is graded on a scale of mild to severe. According to the DSM 5, a diagnosis of substance use disorder (SUD) as it applies to all types of substances requires a minimum of two symptoms from a list of eleven symptoms, which was said to better mirror the symptoms that patients experience (Center for Behavioral Health Statistics and Quality, 2016). Even though substances differ in many ways, they all possess three characteristics that make them vital to public health and safety. To begin with, these substances are all commonly used and misunderstood. Secondly, consuming any of these substances in high dosages or in improper contexts might result in immediate or long-term health or social problems which are referred to as substance abuse. Thirdly, these substances when used at high doses and high frequencies repeatedly can cause a distinct, diagnosable sickness that greatly damages health, and function and may necessitate special treatment, which is mostly referred to as substance use disorders (Thomas McLellan, 2017). Substance use disorders caused by long-term substance abuse are a global problem causing many health conditions that claimed countless lives. In the United States, more than half of adolescents have reported consuming alcohol, and over a quarter mentioned they have also been exposed to prescription and illegal drugs. Both alcohol and drug 2 University of Ghana http://ugspace.ug.edu.gh dependency (1.3 % and 1.8 %, respectively) have prevalence rates of around one-fourth the size of abuse (5.2 % and 7.1 %, respectively). The lifetime prevalence rates of substance use disorders for alcohol and illegal drugs combined are 6.5 percent for alcohol and 8.9 percent for illicit drugs (Merikangas & Mcclair, 2012). According to official data published by US Centers for Disease Control and Prevention, it is reported that faced with the challenges of the COVID-19 pandemic, the issue of drug abuse has even become more problematic among Americans according, revealing America’s drug pandemic to be the deadliest it has ever been. Initial statistics released by the US Centers for Disease Control and Prevention showed that more than a hundred thousand individuals died in the United States from drug overdoses twelve-month months ending April 2021 (CNN, 2021). Similar circumstances exist in Ghana, where drug misuse ranks third among causes of psychiatric illnesses at the Komfo Anokye Teaching Hospital (KATH) and accounts for almost 90% of all mental patients there. The most common causes of mental impairment among young people in the nation are drug addiction and drug dependence. Some of these young people fill the few psychiatric institutions, rehabilitation facilities, and prayer camps, or wind up on the streets (Kasore et al., 2021). Research in the region has been complicated by a lack of resources and documentation issues identifying the genuine patterns of substance usage and associated hazards or implications, leading to a habit of relying on secondary sources. However, secondary sources neglect to look at how drug users perceive and understand drug abuse and the diseases that go along with it. Merikangas et al, in a study, indicated that over 36% of family members of individuals with an alcohol use disorder were also diagnosed with an alcohol use disorder, compared to 15% of family members of the control group (Merikangas & Mcclair, 2012). Drug abuse in most cases leads to substance use disorders, so it's 3 University of Ghana http://ugspace.ug.edu.gh important to revisit the conditions that affect substance abuse in individuals to help decrease the global prevalence of substance use disorders. They engineer many public health issues. Development and security problems are linked to numerous crimes, violence, and social exclusions caused by substance abuse (Sarker & Faller, 2016). Several researchers over the years have shown that various factors contribute to drug abuse, including interpersonal, intrapersonal, and environmental factors (Foo et al., 2012), not leaving out the influence of biological predispositions of individuals. A study conducted by Behere & Chougul (2018) identified parental chemical dependency, peer influence, parental socioeconomic status, behavioral problems, ethnicity, and affective disorders as some of the factors contributing to substance abuse (Behere & Chougule, 2018). Also, individuals who went through child abuse and maltreatment are at well-documented risk of developing problematic substance use and disorder in their teenage years and beyond (Enoch, 2012). In the Ghanaian context, there are few studies on substance abuse, its factors of influence, and its related disorders, and this emphasizes the need for more research on the phenomenon. Consequently, the main goal of this research was to evaluate the risk factors of substance abuse and its related disorders in Ghana. 1.2 Problem Statement A healthy society is crucial to the development of each individual and so is the individual to the health of his society. One of the concerns of the field of public health is to ensure that we develop healthy communities where individuals live a healthy lifestyle based on informed decisions. An analysis at the community level investigates the contexts in which social relationships take place, including family, businesses, schools, and neighborhoods. This kind of investigation aims to pinpoint the aspects in 4 University of Ghana http://ugspace.ug.edu.gh which our environments are connected to substance abuse and substance use disorders. Ideally, a well-built society will be able to provide very comprehensive information on substance use and adopt prevention programs to help the individual and the population to make informed decisions, because substance abuse can disrupt the life course of an individual and impede the development of a whole society. Secured systems contribute to members living a good life and achieving their goals in life, these systems have ideally put measures in place to control and provide enough security measures as to how these substances can be purchased and used. Following global trends, the usage of illegal substances has increased during the past ten years in Ghana. For instance, according to data from the Out-patient Monthly Morbidity Returns (OMMR) of the Psychiatric Rehabilitation Unit of the Regional Hospital in Sunyani, Ghana, 1839 patients reported having mental health issues related to alcohol and illegal drugs in 2015, up from 1046 and 963 patients in 2014 and 2013, respectively (OMMR: Regional Hospital Sunyani, 2016) (Appiah et al., 2018). The rise in cases of substance abuse in hospitals in Ghana has shown that it is impossible to overstate the financial, health, and social toll that substance abuse has on the individual, family, community, and country as a whole. Individual substance abuse has been noted as a significant contributor to crime, some mental illnesses, domestic abuse, several accidents, and numerous avoidable injuries. The creative efforts and contributions of drug abuse victims, which are crucial for achieving healthy communities and national development, are frequently underutilized by society (Arthur, 2018). Though there is dearth of literature on substance abuse in Ghana, few studies in Ghana have shown how Individual substance abuse has affected their communities. However, most studies have been conducted in school settings whereby reports given by adolescents and youths are self-reported. This shows clearly why there are insufficiencies in public 5 University of Ghana http://ugspace.ug.edu.gh education and proliferation in the control system regarding substance abuse in Ghana because little research was done over the years and the settings of study are not specific settings within which individuals can give in-depth account of their abuse. This study aims at exploring substance abuse from the perspective of individuals who developed SUDs as it will help us explore with accuracy lot of factors leading to substance abuse, also to establish challenges faced by SUD patients and how these challenges impede on their personal development. This study will help health promoters to design effective educational guide on substance abuse based on contextual evidence. This study also focused on the commonality of substances in order to help drug regulating bodies to reduce system proliferation. In Sub-Sahara Africa, the prevalence of substance use disorders is expected to have 130 percent by 2050. Despite this, little is known about the region's treatment and preventive services for substance abuse (Jaguga & Kwobah, 2020). Substance abuse is also a problem in the West African Sub-region, which does not leave Ghana as it constitutes in recent years a route where illicit drugs are being trafficked. The significance of West Africa in the transatlantic cocaine trafficking, as well as the influx of illegal migrants to Europe, has recently been highlighted in the worldwide media. West Africa has received a lot of attention in the media and academic studies as a major center of drug trafficking and, to some extent, illicit drug consumption (Robinson et al., 2008). To accommodate the demands in European markets, the transportation of South American cocaine across West Africa and Asian heroin through East Africa had grown since the 1980s and 1990s (Mbwambo et al., 2012). Since ROAPE's inaugural special issue on the subject, the parameters of the continent's involvement in the production, sale, and consumption of pharmaceuticals and illicit drugs have changed significantly (Klantschnig et al., 2016). Looking at the role of West Africa in drug trafficking, the 6 University of Ghana http://ugspace.ug.edu.gh issue of substance use disorders has become a matter of concern as it seems to be acclimatizing in the region as the years progress. In past years, individuals abuse only one substance making treatment easier and more efficient, but poly-substance abuse has become more popular in the last decade, with substance abusers expecting to achieve hige enjoyability. In 2010, health professionals charted a shift from mono-drug use to polysubstance use, and, by 2017 the vast majority of people seeking treatment had reportedly been using more than one substance, typically a mixture of alcohol, marijuana, cocaine, and heroin. Society mostly believes that people who suffer from substance use disorders (SUDs) abuse substances because of their lack of self-control and personal liability, thus they are responsible for their predicament. (Schomerus et al., 2011). This perception makes it difficult for families and communities to assist the abuser in seeking medical service. Thus, this study aimed to better understand the relationship between substance abuse, its influencing factors, and various SUD present among patients.and challenges faced by patients. The study aimed at also identifying substances being abused, and gaining insight into substance use disorders. With this we can eliminate perceptions about caused of individuals suffering from substance use disorders. This study, therefore, proposes an empirical analysis of patients suffering from SUDs and undergoing treatments at Ankaful Hospital whereby a mix of patient-based and clinician-based approaches can be used. The clinician and patient-based approach was proposed to help bridge the gap of accuracy, by controlling the level of truthfulness in patients’ responses. In most studies, substance abuse being a sensitive topic, researchers have identified that participants turn to give false information during interviews; but in this study the clinician and patient-based approach, where information was given in 7 University of Ghana http://ugspace.ug.edu.gh contrast to medical records, this eventuality was reduced which in turn provides an analysis reflecting the true nature of the problem. This qualitative study was conducted within a population diagnosed with substance use disorders because the aim is to explore and describe the phenomenon through the experiences of the population under study from their perspective. 1.3 Research Questions This study aimed at addressing the following questions: 1. What drugs are commonly abused by SUD patients undergoing treatment at Ankaful psychiatric hospital? 2. What are the various SUDs diagnosed among patients undergoing treatment at Ankaful psychiatric hospital? 3. What are the factors associated with substance abuse in SUD patients in Ankaful psychiatric hospitals? 4. What are the challenges faced by SUD patients undergoing treatment at Ankaful psychiatric hospital ever since their abuse became problematic? 1.4 Objectives of the Study 1.4.1 General Objective To explore substance abuse and its related disorders among patients of the Ankaful psychiatric hospital in the Central region of Ghana. 1.4.2 Specific Objectives This study will be guided by the following objectives: i. To explore the commonly abused substances and their related disorders among SUD patients undergoing treatment at Ankaful. 8 University of Ghana http://ugspace.ug.edu.gh ii. To identify the various SUDs diagnosed among patients undergoing treatment at Ankaful psychiatric hospital. iii. To explore the factors associated with substance abuse in SUD patients in Ankaful psychiatric hospitals iv. To explore the challenges faced by SUD patients undergoing treatment at Ankaful. 1.5 Relevance of the Study Most previous research in Ghana on substance abuse was predominantly based on adolescents and was centered largely on school populations and neighborhood samples. These studies are self-reported information collected from the respondents that may have been influenced by fear of being punished or the pressure of being judged for deviating from the normalcy of the educational environment. Most studies on factors influencing substance use disorders or abuse are always conducted in school settings. Conducting this study in the hospital setting will provide a clinical approach to substance abuse issues. Since patients undergoing treatment in Ankaful psychiatric have diverse backgrounds (different tribes, cultural systems, various age groups, and social groups), this study will bridge the population diversity gap. Looking at the emergence of new drugs and the shift to polysubstance use, this study will help us harness in-depth information on this shift in substance abuse and explore the factors which influence substance abuse in Ghana. It will also explore the similarities and differences in factors relating to individuals who started abusing substances from adolescence and those who started abusing substance in the latter part of their life. In addition, aside from serious health consequences, drug abuse has become a flashpoint in the criminal justice system and a major focus of debates about social norms and deviation, with people debating whether substance abuse is a disorder 9 University of Ghana http://ugspace.ug.edu.gh with genetic and biological roots or a matter of personal preference. This study is relevant as it will showcase that apart from biological dispositions, behavioral patterns, other environmental factors also affect individuals’ substance abuse. 1.5.1 Policy This research will help decision-makers by disseminating information and knowledge that will assist them in developing more informed policies and strategies to ensure that substance-related campaigns, prevention strategies, and integrated treatment methods are reformed, improved, and sustained at levels that will effectively provide a much-needed solution to the war on substance abuse and substance use disorders. The findings of this research will also benefit policymakers not to only concentrate on scientific advances but to also consider the social factors influencing substance abuse to generate better policies for the citizens of Ghana. Even though citizens are to be punished when they break the law, there is a need to understand how substance abuse involuntarily becomes part and parcel of some individuals. This will also help Ghana’s government to relook at preventive methods than only punitive methods. 1.5.2 Practice The government of Ghana and Narcotics Control Board (NACOB) organizations are critical in assisting in the development of laws, the dissemination of messages, and the monitoring of issues that concerns the youth and Ghanaians to ensure circulation, consumption, and abuse of substances are put in check. The government, Ghana's Narcotics Control Board, and other security agencies focus more on detainment, prosecution, and extradition of fugitive drug dealers instead of looking more into the factors that influence this legal deviance. The Narcotics Unit, like other divisions of the Ghana Police Service's Criminal Investigations 10 University of Ghana http://ugspace.ug.edu.gh Department, plays an important role so far as substance abuse is concerned, hence, the findings of this study will help them develop policies that will deal with substance abuse and trading with a more pragmatic approach. 11 University of Ghana http://ugspace.ug.edu.gh 1.6 Conceptual Framework of Substance Abuse Socio-demographic and economic characteristic Genetic characteristics 1. Age 1. Genetic vulnerability 2. Sex 2. History of parental 3. Household size substance use 4. Gender 3. Pre-existing disorders 5. Occupation 6. Marital status 7. Educational Childhood and life traumatic experiences Substance Abuse 1. Victim of violence leading to SUDs 2. History of rejection 3. History of abandonment 4. Perceived stigmatization 5. Family dysfunctions So cial support system and network 1. Imitation of peers Environmental characteristics 2. Peer pressure 1. Accessibility to drugs 3. Social acceptance of drug and alcohol sue 2. Parental influence 4. Peer influence 3. Sibling’s influence 4. Parental supervision 5. Family involvement 6. Neighbourhood poverty 7. Abuse within family Figure 1.1 Conceptual Frame Work 12 University of Ghana http://ugspace.ug.edu.gh Narration of conceptual framework This framework was constructed based on the biopsychosocial model which emphasizes the level of influence genetic, psychological, and social factors have on individual decision-making. The onset of drug abuse among all age groups is influenced by a cluster of factors and these factors linking together also cause individuals to indulge in drug abuse. Studies indicated that demographic variables such as age, religion, marital status, gender, employment, and educational background are all characteristics that can impact a person's decision to use drugs (Kasundu et al., 2012). Religion is one of the demographic characteristics that affect how someone may view drug use and become dependent on the rugs, it was shown that some religions have more influence on the frequency of alcohol and drug use than others (Hussain et al., 2019). Religion also plays a larger part in socialization by giving some moral standard to direct one's behavior and social relationships. The level of education of an individual can also affect someone’s decision to abuse drugs, individuals with some level or high level of education are more likely to make self-improvement decisions that are less destructive to them than uneducated individuals who may become dissatisfied and seek solace through substance usage. All these influencing factors are also linked to economic factors that prevail in the individual, your level of income or that of your family will influence the type of housing and the area of residence of an individual. The socioeconomic status of a family is determined by the literacy level of the parents, household income, the presence of both parents, and whether or not these parents are employed (Anyango Aute et al., 2020). A higher socioeconomic status would be associated with a higher household income, a 13 University of Ghana http://ugspace.ug.edu.gh higher level of parent education, full-time employment, and a two-parent household, whereas a low socioeconomic status would be associated with a lower household income, a lower level of parent education, full-time employment, and a two-parent household. All these economic variables in turn will also affect the type of social network the individual belongs to. Another level of influence of drug use is determined by the life events an individual may have gone through, the traumatic experiences such as the history of victimization, emotional abuse, rejection, and abandonment. A life- course perspective for alcohol and other drugs (AOD) research recognizes the role of life events and social settings in influencing alterations in alcohol and other drugs (AOD) use and the problem throughout a lifetime (Jessup et al., 2014). Transitions, social capital, and turning points in life are trajectories to track an individual drug use throughout his lifespan. For many years, people have used alcohol and other drugs to cope with the stress induced by traumatic and disruptive life events (Newcomb & Harlow, 1986). Critical and negative life events occurring in people’s life may alter how they view or use the substance. Biological and genetic dispositions are well explained by nature theories. One theory surrounding substance abuse is that some people may be more susceptible to becoming dependent on narcotics if they have genetic hereditary traits that predisposes them. This by noting that these characteristics of the individual was inherited from a family of substance abuse history, or family that possess genetic predispositions which affect how an individual metabolize substances. According to family research on alcohol use disorders, these disorders tend to cluster in families. In a study conducted by Merikangas & Mcclair (2012), more than one-third (36 percent ) of relatives of those who suffer from alcohol use disorder were also suffering from alcohol use disorders, compared to 15% of the relatives of controls, diagnosed with an alcohol use disorder. 14 University of Ghana http://ugspace.ug.edu.gh Substance abuse is a complex phenomenon that is influenced by many environmental determinants. According the availability-proneness theory of substance abuse, the abuse of substance happens when a person is exposed to a lot of availability. All drugs are said to be extremely difficult to obtain, however, with the proliferation of various systems, it becomes quite easy to obtain. Most importantly, neighbourhood poverty relating to the area in which has been a precipitating factor to substance abuse. For example, availability of substances is more pronounced in slums than any other areas. John Bowlby first developed attachment theory as a behavior-based theory that attempted to explain infant-caregiver connections in terms of evolution (Cihan et al., 2014). Bowlby described attachments as "long-term psychological ties between people. Substance abuse is facilitated by parental, siblings or family influence. Attachment theory explains this by expanding on the link between how an adult collaborates with a child to meet the child's basic needs, food, protection, and long-term psychological effects. Parental involvement is very crucial when a child communicates his or her needs, and the attachment process starts when parents, family or caregiver either responds to those needs in a timely and appropriate manner or does not. These interactions between the infant and the adult establish expectations for the infant, and this will have long-term positive or negative effects. Many theories and models have been developed to explain substance abuse. Some are applicable to some aspect of substance abuse. No single model has been able to explain substance abuse in its entirety, however, using the biopsychosocial model has helped to have all these models come together to complement each other. 15 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter focuses on reviews of related literature on substance abuse. It provides information on the classification of substances, the theoretical framework, substance abuse as a public health concern, socio-demographic characteristics of substance abuse, factors associated with SUD/abuse-related patients, social support and social network, and the challenges faced by SUD/Abuse-related patients. This helps give a broader understanding of the study subject. 2.1 Classification of Substances Drugs are classified based on their characteristics, and drugs of the same class also have similar effects. Regardless of type, all controlled drugs share several characteristics. Mostly, drugs were categorized based on the effects they have on the body of individuals. 2.1.1 Narcotics or Opioids Individuals still refer to all drugs as "narcotics," however, the term "narcotic" now only applies to heroin, opium derivatives, and semi-synthetic alternatives. Alcohol — including all forms of beer, wine, and distilled liquors(US Department of Justice Drug Enforcement Administration, 2017). Origin Natural opioids are derived from the poppy Papaver somniferum, whereas synthetic opioids, such as meperidine, fentanyl, and methadone, are created entirely in a lab. Heroin, oxycodone, hydrocodone, and hydromorphone are semi-synthetic opioids made from 16 University of Ghana http://ugspace.ug.edu.gh naturally occurring opium products like morphine and codeine(US Department of Justice Drug Enforcement Administration, 2017). 2.1.2 Stimulants Stimulants increase the speed of the body's processes. Prescription medications including Adderall and Dexedrine, methylphenidate (Concerta and Ritalin), diet aids like Didrex, Bontril, Preludin, Fastin, Adipex P, ionomin, and Meridia, and illicitly manufactured drugs including methamphetamine, cocaine, and methcathinone fall into this category (US Department of Justice Drug Enforcement Administration, 2017). Origin Stimulants are diverted from legal channels and produced in secret for the black market (US Department of Justice Drug Enforcement Administration, 2017). 2.1.3 Depressants Depressants will put you to sleep, relieve anxiety and muscle spasms, and prevent seizures. Barbiturates are older drugs and include butalbital (Fiorina), phenobarbital, Pentothal, Seconal, and Nembutal. A person can rapidly develop a dependence on and tolerance to barbiturates, meaning a person needs more and more of them to feel and function normally. This makes them dangerous, increasing the probability of coma or death occurrence (US Department of Justice Drug Enforcement Administration, 2017). Benzodiazepines were made to substitute barbiturates, though they still share many of the undesirable side effects including tolerance and dependence. Some examples are Valium, Xanax, Halcion, Ativan, Klonopin, and Restoril (US Department of Justice Drug Enforcement Administration, 2017). 17 University of Ghana http://ugspace.ug.edu.gh Origin Generally, legitimate pharmaceutical products are diverted to the illicit market. Teens can obtain depressants from the family medicine cabinet, friends, family members, the internet, doctors, and hospitals (US Department of Justice Drug Enforcement Administration, 2017). 2.1.4 Hallucinogens Hallucinogens are found in plants and fungi or are synthetically produced and are among the oldest known group of drugs used for their ability to alter human perception and mood (US Department of Justice Drug Enforcement Administration, 2017). Origin Hallucinogens can be produced synthetically in illegal laboratories or are naturally found in plants. Hallucinogens can take several different forms. MDMA or ecstasy tablets come in a range of colors and logos to appeal to young people (US Department of Justice Drug Enforcement Administration, 2017). 2.1.5 Marijuana or Cannabis Marijuana is a psychoactive substance made by the Cannabis sativa plant. Marijuana has over four hundred and eighty different constituents. The delta-9 tetrahydrocannabinol is thought to be the primary component responsible for the psychoactive effect (US Department of Justice Drug Enforcement Administration, 2017). 18 University of Ghana http://ugspace.ug.edu.gh Origin Marijuana is cultivated in the United States, Canada, Mexico, South America, the Caribbean, and Asia. It can be grown in both outdoor and indoor environments (US Department of Justice Drug Enforcement Administration, 2017). 2.1.6 Steroids Anabolic steroids are synthetically manufactured variants of the naturally occurring male hormone testosterone that are abused in an attempt to promote muscle growth, boost athletic or other physical performance and improve physical appearance. Testosterone, nandrolone, stanozolol, methandienone, and boldenone are some of the most frequently abused anabolic steroids (US Department of Justice Drug Enforcement Administration, 2017). Origin Steroids are also diverted illegally from legal sources (theft or inappropriate prescribing). The most common method of purchasing and selling anabolic steroids is through the Internet. Steroids are also purchased and sold by teammates, coaches, and trainers at gyms, bodybuilding events, and colleges (US Department of Justice Drug Enforcement Administration, 2017). 2.1.7 Inhalants Inhalants are invisible, toxic substances contained in everyday items that emit chemical vapors when inhaled, causing psychoactive or mind-altering effects (US Department of Justice Drug Enforcement Administration, 2017). 19 University of Ghana http://ugspace.ug.edu.gh Origin They are found in form of typewriter correction fluid, air conditioning refrigerant, felt tip markers, spray paint, air freshener, butane, and even cooking spray. These substances are often referred to as whippets, laughing gas, huff, or hippie crack. Inhalant abuse includes the misuse of household solvents, gases, and anesthetics and is extremely harmful when inhaled (US Department of Justice Drug Enforcement Administration, 2017). 2.2 Theoretical Framework The Social Model of the Stress of Substance Abuse Many psychosocial theories and models have been combined to create the Social Stress Model of Substance Abuse. According to this concept, an individual's propensity of indulging in drug misuse is impacted by stress levels and the extent to which they are mitigated by stress modifiers such as social networks, social competency, and resources. According to the model, stress may originate in the family, the workplace, education, peer group, and/or community. The way one interprets and copes with stress can have an impact on one's ability to access support and choose acceptable success models. Individuals who have constructive societal systems with their family and co-workers would be able to deal better with stress (Lindenberg et al., 1993). This model was built to understand parameters that affect drug use. According to the model, an individual's probability of using drugs is a role of their level of stress level and the degree of stress modifiers such as social networks, social competencies, and tools to mitigate it (Lindenberg et al., 1993). According to this theory the family, the workplace, peers, and the community can all be sources of stress. However, Individuals who have 20 University of Ghana http://ugspace.ug.edu.gh helpful societal systems with their families, co-workers, and peers will be able to cope with stress. The Problem Behavior and Deviance Theory by Richard Jessor Richard Jessor’s problem behavior theory was derived from the basic concepts of value and expectation in Rotter's (1954, 1982) social learning theory and from Merton's (1957) concept of anomie. Problem behavior theory is a theory that defines behavior as socially characterized as a problem, a cause of concern, or as unacceptable by traditional society's social and/or legal norms and institutions of authority. The theory's central concept is that all behavior is the product of interactions between people and their environments, representing a "field theory" perspective in social science. The Problem Behaviour Theory is a social psychological construct that explains the origin and progression of alcohol and substance addiction, as well as other problem behaviors. Researchers based on the problem behavior theory to explain substance abuse from how parental disapproval of problem behavior, high peer approval of problem behavior, high peer models for problem behavior, low parental controls and support, low peer controls, and low compatibility between parent and peer expectations, and low parent (relative to peer) influence are all factors that contribute to problem behavior proneness in the perceived environment system (Jessor, 1991). The Self-Derogatory Theory by Kaplan Howard B. Kaplan proposed a self-esteem/derogation theory of adolescent deviance that combines deviant peer influences (social learning theory), family and school factors (control theory), dealing with failure to meet conventional expectations (strain theory), and self-concept (symbolic interactionism and labelling theory). Delinquency and drug use are 21 University of Ghana http://ugspace.ug.edu.gh considered as responses by certain adolescents to emotions of poor self-esteem or self- derogation in this hypothesis. According to Kaplan, each person has a "self-esteem motive", to perform acts that reduce negative self-attitudes and increase good self- perceptions. Most people develop good self-concepts as a result of their experiences in traditional organizations and conformance to their expectations. Those adolescents who do not believe this is true will turn to deviant organizations and activities in an attempt to overcome self-defeating attitudes and build self-esteem (Kaplan, 1996). The theory posited that individuals who have developed positive relationships with their family, and friends, may develop a sturdy resiliency and self-esteem, as well as the acquisition of suitable social competencies, while stressors will be seen as challenges by people with high self-esteem and resiliency, who see their surroundings and pressures as under their control, who have a strong sense of personal commitment, and who see obstacles as less frightening. These people are better at dealing with stress than others (Lindenberg et al., 1993), meanwhile, individuals who lack stress modifiers may turn to drugs as a result of peer pressure or other pressures. 2.3 Substance Abuse and its related SUDs, a Public Health Concern i. Substance Abuse in West Africa Substance abuse is a major public health concern in West Africa, but there is currently a paucity of literature on necessary measures to remedy it. When it comes to recognizing drug use prevalence trends, the lack of accurate and credible data is even more striking (University of Nottingham, 2013). Notwithstanding these limitations in data collection, available information indicates that a wide range of psychoactive drugs is misused in the subregion. Though there is a new trend in matters concerning drugs the drugs being abused 22 University of Ghana http://ugspace.ug.edu.gh previously within the subregion include alcohol, cannabis, psychotropic drugs, heroin, cocaine, and other synthetic narcotic analgesics. Alcoholic drinks have been consumed for thousands of years. In most cases, this drug serves as a social unifier, and social drinking is popular at important social gatherings. Popular beverages such as palm wine, local gin, as well as beers, wines, and spirits, are consumed (Adelekan, 2017). When it comes to illicit drugs, the majority of claims regarding West Africa's position in the cocaine trade are focused on national drug arrests, which is troubling because it represents shifts in both drug supply and law enforcement attempts to restrict illegal drugs. The wide range of estimates of West Africa's position in the cocaine trade is also due to its dependence on shaky data (University of Nottingham, 2013). However, there has been a tramadol epidemic looms in Africa, this new phenomenon has been discovered proving that opioid consumption is on the rise. Saapiire et al (2021) stated that after cannabis, which remains by far the most popular globally, tramadol is one of the most extensively used substances for nonmedical purposes in various West African countries. ii. Substance Abuse in Ghana It is quite difficult to trace the emergence of drug use in Ghana because of the dearth of literature. In Ghana, as in the rest of the world, the use of illicit substances has increased in the last decade. However, modes of drug use differ among different groups of users, personality styles associated with drug usage, systems, and distribution locations, as well as factors that promoted drug use among Ghanaians. Nkyi (2014) stated that according to the Ministry of Health and World Health Organization's most comprehensive research on drug use among Ghana's youth, the average age at first use of substances ranged between 14 and 19, with extremes of 6 and 23 years. The most frequently used drugs by the youth 23 University of Ghana http://ugspace.ug.edu.gh were alcohol, cigarettes, cannabis, cocaine, and tranquilizers, according to the results (Nkyi, 2014). Saapiire et al., (2021) in their study also reported that the prevalence of tramadol and codeine usage among students in the Upper West Region of Ghana in elementary and junior high schools is worrying. Tramadol has earned popularity as one of the most often abused pharmaceuticals in the region, according to the respondents. It's no surprise that some local farmers have given it the nickname "Koo da nan hum," which means "farm and purchase cow" (Saapiire et al., 2021). A study by Appiah et al., (2018) conveyed that data from the Psychiatric Rehabilitation Unit of the Regional Hospital in Sunyani, Ghana's Out-patient Monthly Morbidity Returns, a total of 1839 patients reported mental health problems related to alcohol and illicit drugs in 2015, compared to 1046 and 963 in 2014 and 2013, respectively (Appiah et al., 2018). 2.4 Factors Associated with Substance Abuse and its Related Disorders 2.4.1 Influence of Socio-Demographic and Economic Characteristics of Substance Abuse Descriptive research is critical for understanding both natural and problematic levels of drug use. When drug abuse becomes more severe, it can lead to disability and negative life effects, suggesting a substance use disorder (SUD) (Merikangas & Mcclair, 2012). Socio- demographic factors influence greatly an individual’s decision to abuse or abstain from drugs. Out of sociodemographic factors, age is one factor that determines an individual’s decision-making abilities and adoption behaviors, whether risky or not. The lifetime prevalence of use of cigarettes, alcohol, and marijuana among youths increased as age increased. Adolescence is a time when young individuals are vulnerable to a variety of influences, and they involve in a variety of behaviors. In the United States, lifetime users 24 University of Ghana http://ugspace.ug.edu.gh of cigarettes, alcohol, or marijuana typically begin using these substances in their late teens, and rates of lifetime use rise in a predictable pattern with age. The adolescent years are often regarded as a significant risk time for the commencement of alcohol use, with numerous research indicating links between age at first alcohol consumption and age at first alcohol consumption (Kroutil et al., 2010). Early drug use is a major indicator of the eventual development of a substance use problem. A study addressed that the majority of individuals with drug use disorders started using drugs before the age of eighteen and had established a disorder by the age of twenty (Johnston et al., 2019), and those who started using drugs in their early teens have the highest risk of developing a substance use problem. For example, 15.2 percent of people who begin drinking before the age of 14 develop alcohol abuse or dependency, as compared to 2.1 percent of those who started drinking only when they were 21 or older (Substance Abuse and Mental Health Services Administration, 2012). An individual’s awareness of drug use is sometimes dependent on the educational background of the parents. Siddiqui & Salim (2017) in their study of male secondary schools in Jizan in Saudi Arabi, findings reported that students whose fathers and/or mothers had post-graduate educational levels recorded the highest percentages of correct answers, while students whose fathers and/or mothers who did not have any formal education recorded the lowest percentages of correct answers (Siddiqui & Salim, 2017). In the same study, they found out that when it comes to awareness of drugs, youths with a high family income recorded the highest percentage of correct answers, while those with a low family income reported the lowest percentage of correct answers (Siddiqui & Salim, 2017). Though the findings on the relationship between educational background and level 25 University of Ghana http://ugspace.ug.edu.gh of income of the family and the awareness of drugs of the participants corroborate with findings of other studies, some researchers took into consideration only the male population. Economic stability in the family also has been shown to have a significant impact on a person's drug use. Three of the seven participants said that family poverty was a factor in substance addiction (Foo et al., 2012). Being unemployed can trigger a lot of stress, rejection, anxiety, and regular bouts of depression, all of which are high-risk factors for developing a drug addiction. Many people who are unemployed and single resort to alcohol or drugs to alleviate their discomfort and feelings of helplessness. Henkel (2011) conducted an extensive literature review between June and August 2010. In this review, it was stated that unemployed people are more likely to drink too much alcohol and use illegal and prescription medications. They are more likely to smoke and develop alcohol and illicit drug addictions (Henkel, 2011). Compton et al. (2014), in their study, used data from the Substance Abuse and Mental Health Services Administration (SAMHSA)’s 2002–2010 national Survey on Drug Use and Health (NSDUH), an annual national survey of civilian, non-institutionalized individuals. To reduce confounders, Compton and colleagues provided information on education, demographics, residence place, state-level unemployment rates, and previous 12-month symptoms of major depression. The results from their study specified that in every period for race, ethnicity, sex, and age subgroups, the unemployed population had a higher rate of illegal drug usage, tobacco use, and illicit drug abuse/dependence than the working population (Compton et al., 2014). 26 University of Ghana http://ugspace.ug.edu.gh 2.4.2 Influence of Genetic Predispositions Alcoholism is a disease that runs in families. This is most likely due to genetic transmission as well as the familial environment in which people grow. This genetic transmission of alcoholism has been investigated through the twin approaches which evaluate the quantifiable impact of genetic and environmental effects on a specific trait or disease state (Meyers & Dick, 2013). A Harvard Twin Study of Substance Abuse was conducted by Tsuang et al. (2017) where the population of the study was the members of the Vietnam Era Twin (VET) Registry. Over 8000 male twins who served in the US military between 1965 and 1975 were asked about their use of licit and illegal drugs, as well as different forms of psychopathology, as part of the VET Registry. Through this study, genetic factors were found to play a major role in the risk of lifelong substance abuse/dependence, accounting for 34% of the variance (Tsuang et al., 2017). One strength of their research was not limiting their scope to only genetics, but also establishing the substantial impact shared cultural beliefs, and special environmental factors have on illegal drug abuse. Maes et al (2016) used twin and sibling data from Swedish national registry data to model the association of genetic and environmental risk factors in the etiology of substance addiction as determined from medical and criminal registries. This study found significant heritability for substance abuse risk, as determined by medical or criminal records (Maes et al., 2016). 2.4.3 Lack of Knowledge of the Real Effects of Substances (no perceived risk) Most of the time, many adolescents are aware of the various type of substances, however, they are not aware of the negative implications the abuse of these substances can have on 27 University of Ghana http://ugspace.ug.edu.gh them. The findings of Kazdouh et al.’s study, backed up by a Krakow-based study that assessed students' understanding of psychoactive drugs revealed that the vast majority of those surveyed are familiar with the terms "psychological" and "physical" addiction. Students are unable to enumerate the negative health effects of smoking (Kazdouh et al., 2018). Similar to these findings, the following were discovered in another study where students of all genders were educated about the effects of substance usage on the human anatomy and society, the findings reported that even infrequent or frequent use of cigarettes, alcohol, and other drugs was very hazardous. Although the older pupils were more acutely aware than the younger group, the majority of the students saw substance misuse as an issue but they do not have a thorough understanding of what these issues are (Haddad et al., 2010). On the contrary, a study conducted exposed that participants were aware of the types of drugs and their negative effects on the human body. In the study, participants were aware of the negative consequences of substances, such as liver damage from long-term use, oral and throat cancer from chewing tobacco, and HIV from injecting drugs (Nebhinani et al., 2013). 2.4.4 Accessibility of Drugs A study conducted by Wang et al. (2013) using a nationally representative sample, investigated the contextual impact of convenience store availability on recent adolescent alcohol usage in a multi-level setting. After controlling for compositional characteristics, their findings showed that a high level of convenience store availability in a school district affected recent alcohol consumption in adolescents (Wang et al., 2013). 28 University of Ghana http://ugspace.ug.edu.gh Human development is thought to be influenced by contextual aspects of the neighborhood community in which people live. The most fundamental means by which a risky atmosphere can influence drug use habits is by limiting obstacles to obtaining drugs. The obstacles to possessing, utilizing, and abusing drugs are reduced when substances are readily available, making drug use and abuse more likely (Mennis et al., 2016). In their study, they used multilevel models to investigate the relationship between drug usage, drug availability, and child maltreatment using data from a telephone survey with 2,597 respondents from 43 cities with credible police data on narcotics incidents. They found out that parents who live in areas where there are more drug crime incidents and use drugs are more likely to abuse their children physically than parents who live in areas where there are fewer drug crime incidents but do not use drugs (Freisthler et al., 2017). On the other hand, many studies ecological studies of the physical availability of drugs find that higher levels of drug availability were related to higher rates of child maltreatment (Freisthler et al., 2012; Freisthler & Weiss, 2018). 2.4.5 Psychological factors Self-esteem boost and substance abuse/related SUD Association between self-esteem and substance abuse has been discussed in many types of research. A study stated that the average self-esteem score of the patients in this study was found to be at a medium level. This finding can be construed to suggest that substance abusers have lower self-esteem and self-worth (Ersöğütçü & Karakaş, 2016). Intending to establish a link between low self-confidence and substance abuse, research conducted in Turkey also found a substantial link between the Rosenberg self-esteem test results and smoking, as well as illegal drug misuses such as heroin, prescription tablets, alcohol, Nas, 29 University of Ghana http://ugspace.ug.edu.gh and other substances, however, the association was not important for marijuana and opium abuse (Khajehdaluee et al., 2013). Similar but a bit distinct findings were recorded in a research conducted by Fuentes et al., which reported that findings of their study on the relationship between self-esteem and drug use revealed that academic, family, and physical self-esteem were all adversely related to drug use, whereas the social component of self- esteem was positively related to drug use. However, when the teenagers' ages and sexes were adjusted for using partial Pearson correlations and analysis of covariance, the relationship was no longer significant (Fuentes et al., 2020). Affective dysregulations Through the attachment system and modeling, all primates learn how to regulate their affections through their major attachment figures. Parents with substance abuse issues are likely to have their affect dysregulation, which may have occurred before or as a result of their substance abuse. As a result, it will be difficult for children and teenagers to establish good effect management with these parents and their significant others. As a result, children and teenagers are more likely to develop internalizing issues like depression, anxiety, and substance abuse, as well as externalizing issues such as opposition, behavior issues, angry outbursts, aggressivity, impulsivity, and substance misuse (Lander et al., 2013). Muchiri & dos Santos, in their research, identified that lower affection received by adolescents from their parents was associated with increased alcohol use and this affection showed an interactive effect with sharing and behavioral control through guilt, nurturance, warmth, as well as obligations for responsible behavior. This responsible behavior has been discovered to be a significant influence on parenting, which is a predictor of future better improvements in children's development (Muchiri & dos Santos, 2018). 30 University of Ghana http://ugspace.ug.edu.gh Profuse stress and substance abuse/related SUD One of the fundamental goals of psychoactive substance usage is to alter one's mood. People continue to use drugs to escape unpleasant situations in their lives, such as physical pain (opiates), stress (nicotine), and panic/anxiety (anxiety) (benzodiazepine). Vachon et al., (2015) stated that externalizing and internalizing disorders that are linked to faulty reward and emotion processing have a lot in common. Individuals' susceptibility to substance usage may be shaped by the timing of their stress experience. Exposure to early life stress can result in a variety of effects (Vachon et al., 2015) Childhood maltreatment, life trauma, and substance abuse/related SUD Relationships with caregivers that are supportive and responsive are essential for a child's healthy growth. The stress caused by the interruption or lack of these relationships when brain structures are forming has long-term and severe consequences for an individual's emotional, behavioral, social, and physical health and well-being (Teixeira et al., 2017). Many studies have established the impact of childhood maltreatment on substance abuse. However, a lot of researchers seem to neglect the fact that substance use is a risk factor for child maltreatment, and little research has been done about how the drug climate affects parental physical violence and neglect (Freisthler et al., 2017). Another study stressed that interpersonal stress, frustration, and hopelessness associated with substance use may worsen negative affect and depressive symptoms in parents with SUD, leading to over- reactivity during disciplinary events and a higher risk of child maltreatment. During instances of high substance usage, crossover refers to the transfer of experience or influence from one individual to another (Kelley et al., 2015). In contrast to the existence of fewer studies focusing on the more specific relationship between childhood 31 University of Ghana http://ugspace.ug.edu.gh maltreatment and illicit drug abuse (Elliott et al., 2014; Mersky et al., 2013), the relationship between childhood maltreatment and alcohol use and abuse is largely demonstrated in the literature (Brady & Back, 2012). The authors further argued that children who are exposed to tremendous adversity early in life are more likely to develop mental health issues later in life, including alcoholism. In general, the onset of trauma occurs before the onset of alcoholism. Although a direct causative association cannot be shown, this temporal relationship shows a strong and favorable link between early-life trauma and alcohol-related disorders later in life (Brady & Back, 2012), also, current research has emphasized the necessity of measuring trauma in individuals with alcohol use disorders, as well as the beneficial outcomes associated with the adoption of integrated psychosocial therapies that address both trauma-related symptoms and alcoholism (Brady & Back, 2012). A study conducted by revealed Carliner and colleagues revealed that maltreatment of children and interpersonal violence are closely linked to a variety of mental and behavioral problems. When combined with findings from previous studies on a variety of health outcomes, our findings show that these types of bodily and sexual violence have been associated with an increased risk of a variety of negative outcomes, including health behaviors as well as diagnosed disorders (Carliner et al., 2016). Few studies also reported that despite the evidence being limited to the female gender, a history of physical abuse in the past is connected with adolescent drug misuse using a Path Analysis, however, research from another study concentrating on foster care found that any sort of maltreatment could result in a prevalence of cannabis use as high as 85.7 percent for lifetime use and 31.7 percent for use within the last three months (Gabrielli et al., 2016; Nawi et al., 2021). 32 University of Ghana http://ugspace.ug.edu.gh Additionally, Kelley et al., (2015) reported that in both father SUD and dual SUD couples, the results of multigroup structural equation models demonstrated that a parent's report of depressive symptoms predicted their risk for child maltreatment. In both father SUD and dual SUD couples, a parent's account of their depression symptoms predicted their over- reactivity in disciplinary confrontations The same study mentioned that symptoms of depression did not predict a spouse's probability of child abuse or over-reactivity in any of the models, however, the findings highlight the significance of the level of depression in a parent in determining their likelihood of child abuse and over-reactivity during corrective occurrences (Kelley et al., 2015). Despite the well-established correlation between childhood maltreatment and substance use disorders, it is difficult to reliably predict the future link between these two disorders without longitudinal investigations (Green et al., 2010). 2.4.6 Home Environment It has long been established that parents and the home are inextricably linked. Understanding patterns of behaviour in individuals’ use of drugs requires an understanding of their home (Broman, 2016; Kopak et al., 2013). History of Family Abuse Drug usage relationship could be attributable to parental substance abuse, which we account for abuse in children. The use of alcohol and other drugs is frequently influenced by the familial environment. A study through its analyses found out that the majority of the participants agreed that adolescents who used substances had inadequate parenting, particularly their parents or siblings were drug users, thereby implicitly influencing drug use decisions through observation or modeling. These adolescents agreed that their parent’s 33 University of Ghana http://ugspace.ug.edu.gh use of substances influences significantly children to also start abusing (Kazdouh et al., 2018). The occurrence of psychological and emotional development difficulties among their children has been connected to unstable and inconsistent family and living environment elements (e.g., temporary living situations, inconsistent caretaking, aggression) resulting from drug-using caregivers. Children are more likely to use alcohol and other drugs in families where they are used or where views toward their use are positive than in families where they are not used or where attitudes toward drugs are not as permissive (Kenneth J Gruber, 2006). The influence of parental substance abuse on adolescents’ abuse of substances was measured in a study, after the researchers adjusted for ethnicity taking only into consideration the impact of parental legal drug usage on adolescent illegal substance use, the model statistically substantially predicted increased adolescent alcohol substance use. And with each rise in the category of parental illicit substance use, the likelihood of being in a higher category of alcohol use increased 1.5 times (Muchiri & dos Santos, 2018). Parental Marital Crisis, Chaos, and Divorce Little is known about the influence of parental conflict and violence on the mental health and substance use of their children. Schiff et al., (2014) examined whether offspring exposure to parental intimate partner violence, physical violence, conflicts, disagreements, and parental conflicting interactions is associated with offspring depression, anxiety, and substance use in early adulthood. The study then established that growing up in a home with continual nonviolent conflict, whether or not divorce is present, is linked to increased psychological discomfort and worse levels of well-being in young adulthood. In terms of parental chaotic marriage influencing a child’s abuse of substances, a study revealed that 34 University of Ghana http://ugspace.ug.edu.gh in contrast to rigid family systems, chaotic family systems are characterized by a lack of clear role division among members, roles that are unclear and frequently transferred from one member to another, impulsive decisions that are never adequately considered, a constant desire for change, and parents who have neglected their position of authority (Matejevic et al., 2014). Parental Involvement Ecological models show that parental control and adolescent substance use are inextricably linked. Any of the family factors underlying substance addiction are parents’ conduct, involvement, behavioral control, and psychological relationship between parents and their children. It is reported that when both behavioral and psychological control of parents are poor, adolescents have lower levels of happiness, indicating a lack of parental monitoring, attention, and neglectful parenting style (Logan-Greene & Semanchin Jones, 2015). However, evidence from the United States also suggests that when parents exercise high levels of psychological control, adolescent health suffers. This is because the combination of two controlling tactics may cause adolescents to feel troubled and dissatisfied in meeting the demands (Caron et al. 2006). Adolescent substance use is also predisposed to the quality of parental–adolescent relationships. Adolescents would form tight links and maintain good communication with their parents in households with healthy parent-child interactions, which would prevent teenage problem behaviors such as substance use (Kuntsche & Kuntsche, 2016). The level of parent–youth conflict, open communication, and intimacy, which are indicative of the patterns of interactions that generally occur between the parent and teenager, all contribute to the quality of parent–youth relationships. Early adolescence is a period of identity formation and growing independence from one's 35 University of Ghana http://ugspace.ug.edu.gh parents. The attitudes and behaviors of parents have a significant effect on their teenagers' substance usage. Lack of or weak enforcement of rules concerning underage substance use, poor parental monitoring, for example, when parents have little knowledge of their children's whereabouts and activities, and poor or non-existent parent-child communication have all been linked to early-onset and high levels of substance use among adolescents and young adults, according to research (Varvil-Weld et al., 2015). Another study observed that highly conflictual family ties were linked to substance use disorders in late adolescence and early adulthood in a mixed-age cohort (10–16 years old), but did not evaluate good components of the relationships, such as communication and closeness (Skeer et al., 2012). The family environment between the parents and the financial situation of the family can cause an individual to abuse drugs (Foo et al., 2012). Adolescents who have a good bond with their parents and live in a close-knit family are more likely to find care from their parents if they have a serious problem with their abuse (Kopak et al., 2013). Parental Monitoring, Discipline, and Behavioral Control A search implemented where gender, age, parent marital status, and mother job status were all taken into account when assessing adolescent cannabis usage as influenced by emotional support and positive appraisal, it was analyzed that when emotional support from parents was at its lowest level, the probabilities of adolescents abusing cannabis more frequently were 3.7 times higher than when emotional support in adolescents was at its highest level (Muchiri & dos Santos, 2018). In the same study by Muchiri & dos Santos (2018) where parental supervision was defined by parental knowledge of adolescent activities, which strongly predicted increased adolescent alcohol use after controlling for ethnicity, it was shown that with each increase in parental understanding of adolescent 36 University of Ghana http://ugspace.ug.edu.gh activities, there were a 1.8 times decrease in the odds of adolescents consuming alcohol more frequently. 2.5 Social Support and Social Network Many social factors have been linked to Substance abuse, factors such as social acceptance, representation of celebrity use of substances, and appealing packaging of happiness in substance use are frequently linked to the improper usage of substances by teenagers (Gopiram & Kishore, 2014). 2.5.1 Peer Pressure It is important to develop relationships with people of the same age range across the lifespan, however, developing strong bonds till adulthood under the negative influence has been connected to several negative consequences, including criminal behaviors, conflictual relationships, and even an increased risk of early mortality. Foo et al. (2012) stated in their study that four participants stated peer influence to be one of the factors causing their drug abuse. Their peers influenced them by suggesting and persuading them into trying out the substance, and then provided them with the source until participants learned the way to get the source themselves (Foo et al., 2012). The findings of this research are also in line with studies that found that peer drug use has a greater impact on a person's substance use than parental factors(Loke & Mak, 2013). According to Ehsani-Chimeh et al.(Ehsani-Chimeh et al., 2020) (2020), in numerous research, the influence of friends and peers on the acquisition of specific attitudes and behaviors, such as the desire to smoke, was also heavily stressed. Many people start smoking because they want to be like their peers. 37 University of Ghana http://ugspace.ug.edu.gh Because it is so crucial to be accepted by friends during the periods of adolescence and young adulthood, some adolescents may give up on their desires and wish to stay in touch with their friends and peers (Ehsani-Chimeh et al., 2020). 2.5.2 Social Acceptance, Media Portrayal, and Marketing of Substances It is no doubt that in modern times many advertisements of substance have been patronized by the media all across the globe. These excessive advertisements make individuals think that drinking and smoking is socially acceptable behavior, hence, many people started indulging in these risky behaviors after watching consistently these advertisements online or on television. A study conducted by Wakoli (2018) discovered that the link between receptivity to the advertisement and smoking susceptibility was higher than the link between family or peer smoking and susceptibility, implying that advertising has a greater effect than peer or family smoking (Wakoli, 2018). Globalization and media dissemination are two major influences that have influenced and characterized the new generation of young people. Many societal shifts have been realized internationally as a result of changes in the media industry. Media and marketing Themes that cater to youth in smoking material include glamour, independence, rebelliousness, romance, socializing, and celebrating; however, the negative health consequences of smoking are rarely portrayed (Jackson et al., 2019). In the study conducted by Kazdouh et al (2018), it is revealed that negative media effects and a lack of information regarding the severity of substance use-related problems, whether in the home or at school, were cited by participants. Many individuals saw these characteristics as important risk factors that are increasing adolescent drug abuse (Kazdouh et al., 2018). Tobacco companies have mastered shifting platforms to get around the law's prohibitions by marketing through other channels. There is no regulation in the media for 38 University of Ghana http://ugspace.ug.edu.gh generic images of tobacco content; yet, these generic images are arguably no less influential on smoking behavior than branded ones (Jackson et al., 2019). Moreover, many studies have proven that although empirical evidence on the effectiveness of alcohol marketing limitations or bans on young people's use is limited (Siegfried et al., 2014), there is a link between individual exposure to alcohol advertising and young people's attitudes toward alcohol and drinking patterns (Atkinson et al., 2017; Jackson et al., 2019). 2.6 Summary of Literature It is quite difficult to trace the emergence of drug use in Ghana and its influencing factors appropriate to the Ghanaian context because of the dearth of literature. In Ghana, as in the rest of the world, the abuse of substances has increased in the last decade. Most importantly, there is a dynamic constant shift in the commonly used drugs, factors influencing the abuse, and also the medium through which these substances are procured by the youth. This dynamism if not well studied cannot help various authorities know exactly what substances should be of focus, and the causes of abuse to generate more evidence-based prevention programs and interventions. Knowing how these substances were acquired by individuals is essential for preventive and punitive measures. For example, in Ghana, in recent years Tramadol has earned popularity as one of the most often abused pharmaceuticals in the region. While studies work to clarify the reasons for tramadol usage elsewhere, little is known about the factors that encourage young people to abuse the drug because there is inadequate information on the dynamics of abuse of tramadol in the nation (Fuseini et al., 2019). Most importantly, settings within which studies on substance abuse are done in Ghana are basically educational settings that may not present an approximate accuracy of information. This review of literature has shaped the focus of this phenomenological study 39 University of Ghana http://ugspace.ug.edu.gh to throw more light on substance abuse and its relating disorders, to examine the causes of abuse among young people in Ghana and to identify the challenges faced by individuals diagnosed with substance use disorders. 40 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This section addresses the methods used in exploring the listed objectives. The chapter starts with the intended study design followed by the description of the study site, ethical considerations for data collection, inclusion/exclusion criteria implemented during the collection of data, a data analysis tool used during the data collection procedure, and data analysis. 3.1 Study Design The study adopted a descriptive phenomenology design and was conducted at the Ankaful Psychiatric Hospital, Cape Coast, Ghana. Studies on substance abuse have been scarce in Ghana and a descriptive phenomenology was used in this study because little is known about this phenomenon, its precipitating factors, and its current trends in the Ghanaian context. Descriptive phenomenology is used because, little is known about an issue and the study aims to make clear and understand the most essential meaning of a phenomenon of interest from the perspective of those directly involved in it (Giorgi, 1997). A purposive sample of 30 patients (15 patients with mild SUD and 15 patients with severe SUD) receiving treatment for substance use disorders was recruited. With the help of the supervisors who are medical practitioners, the medical records of participants were examined solely by them. A list of various participants who fit the population of interest was prepared by their supervisors. Later a code was given to each participant before the researcher met with them to seek their informed consent. Data were then collected through in-depth interviews with a semi-structured guide and analyzed using the content analysis 41 University of Ghana http://ugspace.ug.edu.gh procedures. This sampling method was used because the researcher had prior knowledge about the purpose of this study which is to gather information on substance abuse and substance use disorders from the perspective of those diagnosed with a disorder as a result of the abuse. The researcher used this sampling method to access a particular subset of patients receiving treatments in the various wards of the hospital because they fit the profile of interest to the study. 3.2 Study Site The study was carried out at Ankaful Psychiatric Hospital. This hospital was established by the late Dr. Kwame Nkrumah, the first President of the Republic of Ghana, established the Ankaful Psychiatric Hospital in 1965. Ankaful Psychiatric Hospital is located in the Komenda, Edina, Eguafo, Abram Municipal Assembly, even though it still maintains links and communications with the Cape Coast Municipality. It is approximately 12.5km from Cape Coast and 6km from Elmina, occupying an estimated land area of about 1.5 square km. It is precisely located in the village called Ankaful where it derives its name; it shares boundaries with Ankaful Leprosy/ General Hospital to the South and the Ankaful Prisons in the west and north with Tsikweikrom village. The Hospital provides specialist Psychiatric services as well as general outpatient services to the public. The facility accepts patients from all regions of the country as well as neighboring states. Foreign cases from La Cote D’ Ivoire, Burkina Faso, Togo, and Benin are occasionally attended to. The hospital has seven wards, namely, Aggrey, Sangmuah, Simew, Forster, Nightingale, Volta, and Twelve steps. 42 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Population The population of this study comprised all patients who have been diagnosed as having substance use disorders in Ankaful Psychiatric Hospital. 3.4 Inclusion and Exclusion Criteria 3.4.1 Inclusion Criteria This study included all patients who have been diagnosed as having substance use disorders at Ankaful Psychiatric Hospital. It also included those above 18 years who consented to partake in the study. 3.4.2 Exclusion Criteria This study omitted patients who were diagnosed with substance use disorders yet have other comorbidities at Ankaful Psychiatric Hospital. Some comorbidities excluded include; depression and bipolar disorder, attention-deficit hyperactivity disorder (ADHD), psychotic illness, borderline personality disorder, and antisocial personality disorder. It also excluded patients who did not consent to partake in the study. 3.5 Sample Size Determination Conventionally, with most qualitative studies, the sample size is not predetermined by the researcher, however, the sample size is reflecting the saturation point of the study (Mason, 2010). Data saturation reflects a situation whereby the researcher will stop collecting data to avoid repetition and duplication. Participants were selected based on certain criteria to be met, which is to have been diagnosed with a SUD or SUDs and not have other comorbidities. These participants were then regrouped into two groups, those with mild substance use disorders and those with 43 University of Ghana http://ugspace.ug.edu.gh severe substance use disorders. For each group interviewed, saturation was reached around the twelfth participant, however, the researcher decided to add three more participants to verify if no new themes will emerge. So, in total, thirty participants divided into two groups were selected for the study. Due to the unique nature of the disorder, all the patients who were conscious enough to give consent, and able to provide accurate responses were recruited and interviewed. 3.6 Purposive Selection of Participants A purposive sampling which is a non-probability sampling technique was used to sample patients from each ward of Ankaful Psychiatric Hospital. Three reasons backed this choice of sampling in the study area. First, the vulnerable nature of the population under study is one issue to look at with great concern. This is to say that the participants of the study cannot be chosen by the researcher herself but through the directives of the supervisors of the wards. Secondly, the hospital deals with a range of patients, including those who abused substances based on their already existing mental conditions, which may not fit the purpose of this study. Lastly, substance use disorders come with a level of severity and issues governing the abuse in someone diagnosed with mild substance use disorders which may differ from those that were diagnosed with severe substance use disorders. Hence, patients were divided into various wards, and from there, an equal number of those who have issues with only substance abuse and SUDs were selected conveniently until the required sample size was met. The study also used secondary data, in the form of various ward supervisors conducting investigations to ensure that the patients selected were not having other comorbidities. The supervisors of the wards anonymously recorded the particular disorders the patients 44 University of Ghana http://ugspace.ug.edu.gh selected to be interviewed were diagnosed with. The investigation served as an evidence- based practice to approve only those who have SUDs and to disapprove patients who may have substance use disorders yet have other comorbidities. The verification was obtained through patients’ folders and the findings were recorded anonymously and given to the researcher. 3.7 Data Collection Tools The interview guide assumed an open format which allowed the interviewees to narrate openly their experiences. The use of this interview guide enabled me to collect factual information on drug abuse among patients. The interview guide contained questions on sociodemographic information of the participants. Another section elaborated on questions about substances commonly abused, while another section comprised questions concerning factors of influence of substance abuse, and the concluding part elaborated questions on challenges faced by SUD patients after their abuse became problematic. Apart from the interview guide, official records (clients’ folders, ward report books, changed books, and admission books) were thoroughly observed by the supervisors of wards as part of the examination of documents. The records were used to reinforce information given by the participants in determining the state of their drug abuse so that the extent to which drugs were abused was revealed. 3.8 Data Collection Procedure The researcher conducted in-depth interviews and individual interviews with the study participants at the wards. A special place was designated for privacy. Two focus group discussions were also conducted, one with participants who are diagnosed with mild SUDs and the other with participants diagnosed with severe SUDs. This helped the researcher to 45 University of Ghana http://ugspace.ug.edu.gh gather vital information to answer all the research questions. During the data collection process, a digital recorder was used to record all the answers that were provided by the respondents after permission was sought from them. To each participant, a code was assigned to ensure anonymity. During the interviews, there were field notes which were later transcribed into data. The recordings were also transcribed and further deleted after the transcription to ensure that no information was divulged to a third party. Each in-depth interview lasted twenty to twenty-five minutes per participant, while each focus-group discussion lasted an hour. Safety protocols regarding COVID-19 elaborated by the Ghana Health service were duly observed. Each interview lasted twenty to twenty-five minutes. The wards’ treatment rooms were used for the interviews by assuring a distance of two meters between the interviewer and the participant. A washing point was already provided by the facility, and face masks and sanitizers were provided which enabled a safe environment for the activity. Each participant was interviewed by assuring the anonymity protocol whereby no third person was allowed around the interview ground. All the respondents were interviewed by the researcher and two research assistants. 3.9 Data Processing and Analysis Transcription of the interviews started each day after the completion of the data collection exercise. At the end of each daily data collection exercise, the researcher always proceeded to transcribe part of the data collected. By the time the data collection exercise was done, the researcher had already been able to transcribe most of the data collected. After the whole process of data collection was done, the researcher spent a few days on the field and completed the transcription. This helped the researcher crosscheck with various participants to confirm whether what was transcribed was exactly what was reported by 46 University of Ghana http://ugspace.ug.edu.gh them. A thematic analysis approach was later used by identifying and analyzing the various key themes and sub-themes in the study. Data were entered into NVivo 11 and then analyzed thematically. Themes and subthemes were developed from the responses and appropriate deductions were made to further empirical evidence. This helped to consider themes as topics that recur in data in one form or another. It was also easier in identifying and categorizing the themes to enable you to carry out a closer and more detailed exploration. Even though part of the analysis was done using the interpretative phenomenological analysis by focusing on the unique responses given by each participant, the major analysis process concentrated more on thematic analysis because of time factor. The study was conducted on thirty participants hence representing a larger sample for an interpretative phenomenological approach to be used thoroughly. Looking at the sample size, and the data collection procedure where in-depth interviews and focus group discussions were used it was safer to focus more on patterned meaning across the data set. The focus is on illuminating details and seemingly trivial aspects within the experience that may be taken for granted in our lives, to create meaning and achieve a sense of understanding. 3.10 Quality Assurance Training Research Assistants To ensure that data was collected effectively, before data collection, a two-day training was given to two research assistants and an interpreter where they were briefed on the aim of the study. During this training, the research interview guide was well explained, ethical issues were discussed, proper handling of research tools was also discussed, and most importantly they were taught how to take field notes effectively. 47 University of Ghana http://ugspace.ug.edu.gh Pilot-Testing of Instrument A pilot test was conducted one month before the main study among SUD patients at the Accra rehabilitation center. This test helped the researcher to ensure that the questions on the interview guide are comprehensible, in that there will be no ambiguities in the instrument during the main study. This pilot study helped the researcher to restructure a few questions on the interview guide that the participants of the pilot test found difficult to understand. 3.11 Limitation of the Study Transcription of some of the interviews from the local language to English was tedious and could have carried some human limitations that are unavoidable. The study was also limited in terms of investigating this phenomenon only in one hospital, this implies that the findings from this study cannot be generalized and be representative of substance abuse and substance use disorders in the whole of Ghana. Despite these few insufficiencies, the study provided good knowledge on issues of substance abuse and SUDs. 3.12 Ethical Consideration Ethical Issues Ethical clearance was acquired from the Ghana Health Service Ethical Review Committee for approval before the beginning of the research. With the ethical clearance from the Ghana Health Service Ethical Review Committee and an introductory letter from the School of Public Health, authorization was required from the Medical Director of Ankaful Psychiatric Hospital to enable data collection. After a review of the proposal, a local ethical clearance was then obtained from the Ankaful Psychiatric Hospital before the data 48 University of Ghana http://ugspace.ug.edu.gh collection commenced under the guidance and instructions of the supervisors of the various wards of the Hospital. In addition to these processes, informed consent letters were also given to the various selected participants to give their consent before the commencement of the study. These forms were read in English and interpreted in Fante when necessary. Privacy and Confidentiality The data shared by participants during the study were confidential to the principal investigator of the study. Given this, participants were given codes instead of using their names. All the information received from the participants was not shared with any third parties. Conclusively, the information of participants was not divulged to any other person before, during, and after the study was conducted successfully. Possible Risk and Discomfort There was a slight risk in conducting this study. The study carries the risk of loss of confidential information with potentially dire consequences. However, the risks discovered during the study were properly addressed. A slight uneasiness was experienced during the contact hours and questions about particular substances abused or their present diagnosis. However, the presence of the supervisors of the wards helped in assuring and building trust between the respondents and the researcher. Possible Benefits The study will equip the hospital to have a fair idea of the factors of influence and the challenges faced by the patients to better design the reinsertion of their patients into their various communities to avoid possible relapse. This study will benefit the patients when the challenges identified in this study will be presented to the various authorities and this will help in designing evidence-based interventions. 49 University of Ghana http://ugspace.ug.edu.gh Voluntary Participation and Right to Withdraw Partaking in this research was entirely voluntary. Participants were not forced to respond to interview questions if they felt uncomfortable. They understood they were allowed to pull out of the study at any given moment. They were also given room to refrain from answering any question(s) they find uncomfortable and which may arouse them negatively. The participants were made to understand that there would not be any negative impact in any form if they choose not to participate or continue with the study. Nonetheless, the participants were given reasons to contribute fully to this study as the data collected will go a long way to help them and others who experience substance abuse and are diagnosed with substance use disorders. Data Storage and Management Data gathered from the study was stored on a pen drive and an external hard disk drive. Data was also transferred onto the computer of the principal investigator. The location of all storage devices and passwords of the electronic databases into which the data was entered was available to only the principal investigator. Conflict of Interest The researcher did not have any conflict of interest. 3.13 Compensation Participant’s participation was voluntary, however, there was refreshment in form of compensation to show appreciation for the efforts and time spent by the participants in taking part in the research. 50 University of Ghana http://ugspace.ug.edu.gh 3.14 Funding Information The study was solely sponsored by the principal investigator. There was no external funding provided. 51 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the findings of the study on the various research objectives. The study explored factors influencing substance abuse, the various substance use disorders identified in the patients, and challenges linked to their substance abuse. 4.1 Background Characteristics of Participants The sample of thirty participants was categorized into two groups, the first group constituted of fifteen participants with severe substance use disorders while the other fifteen participants were made up of patients with mild substance use disorders. Thirteen of the participants with severe SUDs are aged between 18-21 years while the remaining two are aged between 22-23 years. Out of this group of participants, twelve participants dropped out of school after their junior high school while three had a diploma before dropping out of school. All participants with severe SUDs mentioned Christianity as their religion. Meanwhile, out of the participants suffering from mild SUDs, three are aged between 25- 30 years while five are aged between 30-35 years, and the remaining seven are above 40 years. Eight participants dropped out of school before senior high school, five with a diploma, while the remaining two participants had their Bachelor’s degrees. 52 University of Ghana http://ugspace.ug.edu.gh 4.2 Commonly Abused Substances among SUD Patients of Ankaful Psychiatric Hospital Commonly abused substances by patients were assessed by asking the participants to mention the particular substances they abused. From the analysis of the responses given by participants suffering from mild and severe SUDs, several substances were mentioned including alcohol, cigarettes, cannabis, tramadol, amphetamine, cocaine, heroin, and pethidine. However, all participants with severe SUDs stated abusing more than one substance at a time. Out of the fifteen participants diagnosed with mild SUDs, three indicated they abused alcohol, two stated they abused Pethidine, one abused tramadol, two abused Nicotine, four abused cannabis and the remaining three participants abused multiple substances. Out of the fifteen participants diagnosed with severe SUDs, one abused alcohol, three abused heroin, one abused Nicotine, three abused Cannabis and the remaining seven abused multiple substances. From these statistics, it is clear that the abuse of illicit drugs is more prevalent, and polysubstance abuse was more prevalent in participants. 4.3 Distribution of Substance Use Disorders Diagnosed among SUD Patients of AnPH From the data gathered (shown in Table 1), out of the 50 % diagnosed with mild SUDs, 13 participants are males representing 43.33 % while the remaining 2 are females representing 6.67%. in contrast, out of 50% of participants diagnosed with severe SUDs, 14 participants are males representing 46.67% while the remaining one is a female representing 3.33%. Out of all data gathered, 4 participants representing 13.33 % of the total sample were diagnosed with an alcohol-induced disorder, 6 participants representing 20 % were 53 University of Ghana http://ugspace.ug.edu.gh diagnosed with opioid use disorder, 3 participants representing 10% were diagnosed with Nicotine use disorder, 7 participants representing 23.33% was diagnosed with Cannabis psychosis, while the remaining 10 participants were diagnosed with polysubstance psychosis. Table 1: Distribution of substance use disorders diagnosed among the SUD patients TYPE OF SUD Number of cases identified DIAGNOSED Percentage MILD SEVERE Male Female Male Female Alcohol-induced disorder 3 0 1 0 4 (13.33 %) Opioids use disorder 2 1 2 1 6 (20 %) Nicotine use disorder 2 0 1 0 3 (10 %) Cannabis-induced psychosis 3 1 3 0 7 (23.33 %) Polysubstance psychosis 3 0 7 0 10 (33.33 %) 13 (43.33%) 2 (6.67%) 14 (46.67%) 1 (3.33%) 30 (99.99%) Description of the disorders from the clinician perspective: 4.4 Alcohol-Induced Psychosis Some patients have been diagnosed with alcohol use disorder due to heavy drinking of alcoholic beverages. This psychotic condition is causing acute intoxication in four participants with severe SUD which has manifested in the forms of shakiness, and loss of appetite. 4.4.1 Cannabis-Induced Psychosis This disorder is the most diagnosed among the majority of the participants who had abused substances and as a result, developed a disorder. Cannabis has been the drug most abused 54 University of Ghana http://ugspace.ug.edu.gh by both participants with mild and severe SUD. Participants suffering from Cannabis- induced disorder sometimes expressed emotional responses such as unexplained anger, excessive talking, a high level of suspiciousness, and sometimes disorganized thoughts. 4.4.2 Nicotine Use Disorder This disorder occurred in participants after the nicotine dependence grew over time. Participants who abused Tobacco products such as cigarettes on daily basis. The frequent smoking of cigarette of participants has led to body adaptability which led them to smoke heavily and increase their frequency of smoking leading them to addiction. After the disorder sets in, some participants reported lacking concentration, being easily irritated, and angry. 4.4.3 Opioids Use Disorder The psychological reliance on Pethidine and Tramadol, pain relievers caused this disorder in two participants (mild SUD) who abused Pethidine, and three participants (severe SUD) who abused Tramadol. These drugs when injected interacts chemically with opioid receptors on nerve cells in patients’ body and brain reducing their feelings of pain. Patients complained that within just eight weeks into use, they already developed a physical dependency. The disorder that occurred after continuous use has caused tolerance, dependency, and problems in participants’ daily life. 4.4.5 Polysubstance Psychosis This disorder was due to patients abusing various substances during the same period. These substances when interacting with the body develop various health problems. Because this nature disorder is a multiple disorder, it becomes difficult for health professionals to provide treatment to manage the episodic reactions of the patients. 55 University of Ghana http://ugspace.ug.edu.gh 4.5 Factors Influencing Substance Abuse and SUDs Following the analysis of transcripts of the two focus groups, and in-depth interviews on factors influencing substance abuse and SUD in participants, this set of overarching themes below emerged. 4.5.1 Curiosity (New experiment) The discourse from the two focus groups and the various in-depth interviews (participants who abused substances and have been diagnosed with mild substance use disorder, and those who abused substances and have been diagnosed with severe substance use disorder) reported that they tried multiple substances because they wanted to know the feeling they bring. They expressed not having any particular reason except for the fact that they were curious about the feeling of ecstasy as individuals who drink or smoke feel. One of the participants suffering from alcohol-induced disorder stated: “When I decided to drink alcohol and try different types of alcoholic drinks, no one introduced me to these drinks. I just wanted to experience that feeling of ecstasy and happiness. I see individuals drinking alcohol and I see how they behave. They look extremely happy so I also wanted to know that feeling.” ____ (Kofi) “I wanted to know how it feels like and I wanted to also try. Friends told me that when they use drugs they get “high”, they always described how the feeling is when you smoke Marijuana or cocaine. So, I wanted to know about that feeling so I tried it to see how it will be.” ____ (Ama) 56 University of Ghana http://ugspace.ug.edu.gh Another participant who has developed Cannabis-induced psychosis stated: “Though my friends were into it, I would not say they introduced me to smoking drugs. They told me about Cannabis and advised me to try it and get a good feeling. I could have still said no to them, however, because I was very curious about the feeling they eulogized, I decided to take it. Mine was out of pure curiosity and before I knew it, I could not go a day without it.” ____ (Kwodzo) 4.5.2 Easy Accessibility Participants from both groups indicated that easy access to alcoholic drinks, prescription, and illicit drugs have played a major role in participants abusing the substance. The fact that it is very easy to have access to these substances emerged as a theme throughout the interviews conducted. Participants were asked to give their view on whether easy access was a contributing factor to their abuse and most expressed their view on how getting substances easily has strengthened their dependency. “In my hometown, Tinka island, drugs are sold almost everywhere. It was not hard to get what you want. This made me indulge in smoking multiple substances. I Started with Cannabis, one day I went to buy cannabis and there was a shortage. The guy then convinced me to get Cocaine instead, that’s how easy it was to move from one drug to the other.” ____ (Kobla) “I am a nurse; I was abusing Pethidine. In my field of work, it was not difficult for me to have access to the substance I was abusing. As a nurse, I did not always send 57 University of Ghana http://ugspace.ug.edu.gh a prescription to get it at a pharmacy where I am known as a nurse. Sometimes, I can even get the prescription from my friend’s office. I just prescribed it myself and then proceed to buy it at a pharmacy where they don’t know me. I believe this was also a factor that contributed to my abuse.” ____ (Kobby) The analysis made of the focus group discussions engaged with the two groups also confirmed that respondents perceived cheap prices, easy accessibility of these substances, and availability of drug dealers around schools and every corner of the community to be an influencing factor in their abuse. “Even though the law does not allow the use of some of these substances, it is sold almost in every community. People think these are sold in only slums, but there are strategic points within every community, some are hidden and some are not even hidden. Substances like Tramadol, Marijuana, and Cocaine can be purchased easily within communities.” ____ (Kosi) “After my friends introduced me to drugs, they showed me the dealers that roam around our schools. They also showed me every hidden corner in our community where I can get these substances to buy. I would say, what influence my abuse is the cheap prices at which they sell these substances. That made me buy it multiple times within the day.” ____ (Yaw) 58 University of Ghana http://ugspace.ug.edu.gh 4.5.3 Enhancement of Learning and Academic Performance The discussions with the group of participants who have been diagnosed with severe substance use disorder acknowledged that the need to enhance their learning abilities and perform better during exams was one of the reasons why they started abusing substances. They ascertained that when they started using these substances, they were able to learn better, this pushed them to increase the dose and frequency at which they were on these substances. “I did not have good skills when it comes to learning so I was finding it difficult to concentrate on my studies, my performance was very poor and my parents are always complaining. But I realized that when I was introduced to drugs, I was improving my concentration on my studies. So, I started increasing the dose because I was benefiting from smoking.” ____ (Kwame) The majority of the participants with severe SUD pointed at academic failure as one of the reasons why they decided to abuse substances. They noted that when they increased the frequency at which they were on these substances, they realized that they had better performance in their academics. “I was failing at school. I was always unhappy I did not perform well during exams. I didn’t want to use drugs but when my friends told me I could learn better when I smoke, I did not hesitate. When I started smoking, I started learning better and could stay awake for a longer period. Realizing I performed better after being on 59 University of Ghana http://ugspace.ug.edu.gh the substances, I increased the dose and frequency till I could not do away with them.” ____ (Kwabena) 4.5.4 Lack of Awareness (No Perceived Risk of Substance Abuse) Associating lack of awareness and substance abuse emerged as an overarching theme. Participants with severe SUD recognized this factor as an influencing factor while those with mild SUDs did not see this as a contributing factor because they started abusing a substance at the adult stage of their life. All ten participants emphasized this point by agreeing that not having access to the right information on drugs influenced their abuse. One of the participants emphasized this by saying: “I knew nothing about this. I didn’t know about any negative effects of abuse of substances, be it alcohol, prescription, or illicit drugs. If someone were to given me the right information, I would not have used them. I would have stayed clear away from drugs. So, I will say lack of right information on substances also influenced my decision to start abusing alcohol and drugs.” ____ (Nana) This association was reinforced by another participant by saying “As for me, I knew it was used for fun. I learned that friends smoke it for fun. I did not have any other information on it, especially how negatively it can affect me. I was told if I use it, it will help me to learn better and that led to me abusing Marijuana. I would have abstained from using substances if someone were to tell me about the real effects it can have on me.” 60 University of Ghana http://ugspace.ug.edu.gh ____ (Akosua) “Friends were having fun while using these substances. I was aware of the different types of substances that are circulating in the system. I was also aware of the effects it can have on the human body, most especially the feeling of ecstasy but I did not know about their long-term negative effects.” 4.5.5 Negative Home Environment The majority of the participants with severe SUDs reported a negative home environment to have had a great effect on them becoming addicted to drugs. They reported that their parents’ divorce had a great impact on them abusing the substance. They reported that their parents’ marital situation had exposed them to negative growth. “I had a very troubled childhood, my father abandoned my mother and me. I did not see my father for many years. It made me very unhappy. My mother is mostly not around and she leaves me with people who do not love me. I had an unhappy childhood, that made me follow friends who abused drugs and alcohol.” ____ (Afi) “I am from a home where my father and mother quarreled frequently. As a child, I did not understand why they are always fighting. Mostly I leave the house because there is no happiness and I move with children in the neighborhood. So, when I grew up a little bit, I started drinking alcohol, smoking marijuana with them”. ____ (Kobla) 61 University of Ghana http://ugspace.ug.edu.gh Few respondents with severe SUDs also mentioned that chaos, lack of parental involvement, and a non-caring home environment, as well as no clear norms of conduct at home, have been risk factors that maximized their drug abuse. One of such participants expressed his views in these words: “They are constantly angry with each other and sometimes shout at me. They take care of me sometimes but when they start fighting, they neglect me. There is no supervision so I do things on my own. Hence, when I get frustrated, I turn to my friends and we smoke to have fun. I can forget my worries when I do this.” ____ (Kwabena) “My parents never thought me about social life. They never checked where I was doing. There were no rules to guide my decisions. I take most of my decision on my own as a child. I did not have the chance to be shown the right way. Most of the things I did, I learned from my friends.” ____ (Dauda) “… but in my home, my father barely checked on what I was doing. Sometimes I even smoke in my room without him knowing. It was hard for him to always check where I was and what I was doing. He knows of my friends, but he did not know the kind of things I was doing with my friends, he did not know they were into smoking Marijuana.” ____ (Kofi) 62 University of Ghana http://ugspace.ug.edu.gh Few participants with severe SUDs also associated their abuse with parental influence. They believed that seeing their parents also using substances had influenced their abuse of the substance. Their perception was that it was the duty of their parents to set the right example for them, however, their parents were rather the first person they saw abusing substances. Even though they recognized peer pressure to have been the main influencing factor, they also considered their parental influence as a secondary factor. One of the participants with severe SUD narrated the experience in these words: “Growing up I saw my parents drinking alcohol, smoking cigarettes and marijuana. They were also into it but not heavy like me. Just that they were not deep into it. Even though it was my friends who pushed me into drinking and smoking, I would say, at a tender age seeing my family engaging in drugs, especially my dad, had influenced my decision to also be on substance.” ____ (Xorla) However, when it comes to the home environment, seven participants suffering from mild SUDs pointed to their marital situation as a great factor that influenced their abuse of substances, they recognized their marital situation as a great factor of influence. “I have a child already. But I suffered from miscarriages and my husband’s family blame me for not having other children. They wanted me out of the marriage. My husband even makes it so hard for me, every evening, anytime he returns from work, he will verbally abuse me. To avoid going through constant altercations, I started abusing Pethidine which is a prescription drug, as a pharmacist I know it will help me to sleep.” ____ (Setor) 63 University of Ghana http://ugspace.ug.edu.gh 4.5.6 Psychological Issues In explaining the psychological factors associated with substance abuse, a lot of overarching subthemes such as self-esteem boost, relaxation from stress, escape from the problem, and failure in life were identified by most of the participants to be factors that influenced their abuse of the substances. Many respondents from both groups argued that they found themselves mostly in situations that drained them emotionally and they are constantly frustrated with life events, hence, to release themselves from the stress they turn to abuse substances that help them to relax. They noted that this practice helped them to escape from thinking about their problems. “I was working but I was still not able to fully take care of my family. The work is so exhausting but the pay was not encouraging. I tried so much to look for better opportunities but all to no avail. The worst is I was laid off from this job. After several months of trying and I was not getting any job to do, I started drinking and smoking heavily. This helped me to take away my frustrations and stress”. ____ (Koku) “I had to inject myself with pethidine because I did not want to think about the problems, the stress and anxiety from everyday quarrels and misunderstandings between my husband and I. the situation was draining me emotionally and cognitively, I had to continue abusing Pethidine so I can sleep and forget about my traumatic experiences with my husband and his family.” ____ (Senam) 64 University of Ghana http://ugspace.ug.edu.gh Few participants offered statements why they found it difficult to restrain from abusing substances because of self-confidence boost, they argued that being on substances makes them feel on top of every situation without a sense of embarrassment. Participants from both focus group discussions agreed that being on substances makes them bold giving them a feeling of being important and heard. They also mentioned that being on substances makes them face everyone without any fear. Few participants addressed this by sharing their experiences. “I used to be a shy type and I could not do anything without feeling embarrassed. Initially, I found it difficult to approach a lady and expressed my feelings because I feel embarrassed most of the time when ladies reject me. However, ever since I started being on substances, I could boldly ask a lady out and speak my mind in front of any lady. The intake of alcohol and drugs boosted my confidence.” ____ (Kwame) “After trying weed for many weeks, I became bold and poke my mind regarding issues that I could not talk about. I have been maltreated by my boss for so long at work so when I used this substance, I was able to tell him about my feelings and how badly he has been treating me”. ____ (Nana Kofi) 4.5.7 Peer Pressure Responses from participants of the two focus group discussions and the various in-depth interviews conducted have revealed that peer pressure is one of the major factors that led them to their abuse. Some participants mentioned that after so many insistences from their 65 University of Ghana http://ugspace.ug.edu.gh peers, it was difficult for them to reject their offer to smoke and drink because they wanted to feel among others. “We all have friends apart from our family that we associate ourselves with. With these people you share the same values and interests, so is evident that you move with the most of the time. My friends were into alcoholic drinks and cocaine, they insisted I tried on so many occasions, and one day I ended up smoking it. From there they keep buying these substances for me and making me smoke more often.” ____ (Afi) “Anytime I closed from work, my friends used to invite me out. In the beginning, I did not agree with their lifestyle…and they finally deserted me. I felt rejected and because I wanted to be accepted by them, I started joining my friends on their outings. with time, they started giving me pressure to also smoke weed, I started and later saw that I could not do away with the smoking.” ____ (Dela) Most participants also mentioned that they had issues in their homes and the only place they feel accepted was among their peers. They stated that the constant yearning for acceptance from their peers left them with no choice but to flow with their practice. This a participant expressed by stating that: “It is nice to feel cared for and accepted by the people you love the most. I did not have that my whole life. My family did not have time for me, I was not accepted by my extended family. My friends were the people who accepted me and understood 66 University of Ghana http://ugspace.ug.edu.gh my situation best, being in their company made me abuse codeine and weed but those moments were the best of my life.” ____ (Selorm) 4.5.8 Social Acceptance and Media Marketing In today’s world, digital media use exceeding the use of traditional marketing was reported to be one of the influencing factors to substance use in both adolescents and young adults because they are high users of social media. Participants from both groups expressed that they were easily influenced by some of the content they consume from these various social media platforms. They stated that advertisements for alcoholic beverages and cigarettes on television have greatly influenced their abuse. “I was always excited about new products, these adverts pushed me to buy and try them. I was ready to try new alcoholic drinks and leave out old ones that I was no more interested in. Because these companies keep producing, I keep drinking and changing brands.” ____ (Yayra) “These advertisements encouraged me to drink more and smoke more. I see strong men in these advertisements drinking and smoking, so it makes the act socially accepted.” ____ (Elolo) 67 University of Ghana http://ugspace.ug.edu.gh Some participants also stated that watching people smoke licit and illicit drugs movies, the fantasies surrounding drug cartels, mafia gangs, and how successful they are in the movies gave them a good feeling and more confidence in their abuse. “I saw that people always make merry in movies having drinks all around them. I also saw how people feel hyper when they take drugs. This reinforced my desire to always smoke. It makes me feel that is a habit that exists in all parts of the world. Even though in some movies those who abuse drugs get punished by the law, I am always amazed when I see the mafia gang trafficking these drugs and also smoking their big cigars.” ____ (Nhyira) “Watching these acts in movies made me also indulge in it more. I will not say this initially pushed me into drinking alcohol and smoking drugs but it encouraged my ways. It made me feel it is normal for every youth to indulge in such behaviors.” ____ ( Adjetey) 4.6 Challenges Faced by Patients Suffering from SUD Both groups expressed similar challenges regarding how the abuse of substances has affected them negatively. The various themes that emerged from the interviews are emotional reactions, stereotyping, discrimination, exclusion from major decisions, financial difficulties, loss of respect, loss of social status, career and academic disruptions. 4.6.1 Emotional Reactions Constant negative emotions are going through the minds of individuals suffering from substance use disorders (SUDs). These emotions can range from fear of confidentiality to 68 University of Ghana http://ugspace.ug.edu.gh anger due to guilt of societal judgment. They also reported experiencing episodic emotional effects such as depression, anxiety, loneliness, and boredom. These underlying negative emotions are linked to the belief that the act of abusing substances is linked to failing to follow some moral standards. “I am mostly angry at myself because I feel a strong sense of guilt within me. Even though I know I did not intentionally start abusing a substance, I sometimes feel I could have avoided it. I still get angry because society does not understand what I went through and the reasons why I went in in the first place. This is a constant situation you deal with all the time.” ____ (Kwame) “Anytime I see people look in my direction, I feel so embarrassed. I leave in constant fear of my confidentiality being disclosed by people who know me to new people in my neighborhood. It is when people hear that you have a disorder that they start avoiding and discriminating against you. All this creates a vague of negative emotions within you and it pushes you to resort more to the use of the substance.” ____ (Kwabla) 4.6.2 Stereotyping and Discrimination According to all participants, stereotyping is a major issue or challenge to individuals suffering from substance use disorders. They mentioned issues such as society seeing them as dangerous, unreliable, and unpredictable. 69 University of Ghana http://ugspace.ug.edu.gh “In our society, if you are said to have problems linked to substance abuse, most especially hard drugs, people begin to think you are even more dangerous than those having mental issues. They don’t want to have anything to do with you because they perceive you to be unreliable and cannot be trusted. This has affected me ever since my abuse became uncontrollable.” ____ (Kujo) “I was discriminated by my neighborhood. Parents told their children not to get closer to me because I was going mad. Anytime I sent the children to buy me something, they will restrict me from going and tell them I am a dangerous person. They even told them I can kill them anytime my madness comes back, so they should not come close to me, because I will surely harm them”. ____ (Efo) Most participants also pointed to attributional beliefs as one stereotype issue that makes it even more difficult for individuals to be willing to help them. They also stated that the constant blame society holds against them has been one main challenge that made them not receive the necessary help when their addiction became uncontrollable. One respondent expressed her view of society on them being responsible for their predicament in these words: “Family members always said to me that I brought it all upon myself. They always blamed me for my condition and said no one asked me to start abusing the substance. They practically denied me help and did not also care to know what I was going through with my husband and his family. When I begin to think about all 70 University of Ghana http://ugspace.ug.edu.gh my problems, and also my family refusing to understand my situation my heart breaks a lot and I have to resort to more injections of Pethidine to forget about my worries.” ____ (Kofi) 4.6.3 Exclusion from major decisions They also stated that society sees them as individuals who are unable to make decisions. They lamented on decisions being taken about them without their consent, as society views them as individuals who cannot make rational decisions. “When my abuse became problematic, they stopped involving me in major decisions regarding the family. Most times when I try to make suggestions, they even laugh at me. They go as far as throwing insults on some occasions just because they feel I cannot contribute positively to decisions.” ____ (Kobla) “My wife stopped involving me in major decisions concerning our children. She always felt. I cannot contribute anything positive to the development of my children. She did not allow me to even advise my children and sometimes make me feel like I am a fool. I know sometimes I behave in a certain way but it is not all the time. When I think about all this and how my children have driven away from me, I drink more so I can forget about the constant humiliation.” ____ (Paa Kwesi) 71 University of Ghana http://ugspace.ug.edu.gh 4.6.4 Loss of Respect and Social Status All participants of the study mentioned their loss of respect and social status as one key challenge that they are facing ever since their abuse became a concern to themselves and others. They reported that no one within the society respects them anymore and does not see them as valuable human beings. They also raised the issue of social status where some of the participants lost their role as community elders and was removed forcefully from leadership position because they could not control their abuse. They considered this situation to be shameful to the point that even the younger ones in their communities do not respect them any longer. One participant expressed his point by saying: “I used to be respected within my community. I did a lot to see the development of my community. However, when problems became too much, I found solace in drinking and smoking cigarettes. No one knew was I was going through; I was having serious issues in my marriage. They removed me from my position as the men’s group leader, something I consider shameful. Sometimes, they throw on me abusive words, because I lost the respect, they had for me.” ____ (Afi) Another participant narrated his experience by stating: “One day, I sent one small boy to buy me beans by the roadside. I stay in the same compound with my parents and we were good friends before my disorder set in. The mother of the child came in looking for the child and I informed her that I sent the child to buy me something. She insulted me mercilessly and told me that if I was not using my money on drugs, I would have been married and have my children to 72 University of Ghana http://ugspace.ug.edu.gh send on errands. I was very hurt to the point that I have to smoke myself to sleep so I can forget the hurtful words.” ____ (Kwodzo) 4.6.5 Academic and Career Disruptions The majority of the participants with mild SUD indicated that they lost their job when the disorder set in. They reported low performance at work and the inability to concentrate on their task on the job. Some reported losing their job in the process, few participants stated losing their investments while some lost their businesses. “I could not perform very well at my workplace. They gave me some time off to readjust myself, but upon returning to work, my performance even became worst because of my abuse. I was finally sacked from the work.” ____ (Nana) “I was an entrepreneur; I had my own business in selling spare parts and I also repair cars. Most of the time I was unable to go to the shop to supervise my shop attendants. Sometimes, even if I go to the shop, all I was interested in is finding out the sales they made so I can collect the money to buy more drinks. The attendants stole from me and the business collapsed.” ____ (Yakubu) However, most of the participants with severe SUD experienced disruptions in their academics. One of the participants reported this: 73 University of Ghana http://ugspace.ug.edu.gh “First when I was abusing Tramadol, I could learn so well and was always energetic. But it got to a time, I could not concentrate any longer. I always had divided attention in the classroom. Sometimes, I can be in class but cannot wait to get out so I can get high more. After failing multiple times, I had no option but to drop out of school.” ____ (Kobby) “School was no more fun. I preferred being with my friends, smoking, and having fun. I was not enjoying school because my grade was getting worst and I was frustrated. I preferred to drop out from school than to be mocked by my classmates because of my bad grades.” ____ (Senam) 4.6.6 Financial difficulties Most participants concluded sustaining a lot of financial loss and difficulties because their engagement in substance abuse ruined their finances and also the treatment and rehabilitation are so expensive to the point that they are now having financial difficulties. One participant stated that: “I spent a lot of money on drugs. I was doing a part-time job and I had some savings but I spent it all on different drugs. Now I don’t have anything and my mom has to struggle before getting money for my treatment.” ____ (Yayra) 74 University of Ghana http://ugspace.ug.edu.gh “I used all my salary in purchasing Pethidine. You know, it is an expensive drug. When I developed tolerance, I had to purchase more of it, sometimes I can use all of my salaries to buy the whole package to avoid shortage. I was spending on this drug; I exhausted all my savings; I could not complete my house and I also sold my taxi I was using for extra income.” ____ (Elolo) 75 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.0 Introduction This qualitative study was designed to explore substance use disorders, factors associated with substance abuse, and challenges faced by patients suffering from substance use disorders at Ankaful Psychiatric hospital in Ghana. Prior studies did not focus on exploring whether factors contributing to substance abuse in an adolescent will be similar to factors of influence of substance abuse in an adult who started abusing a substance at a later part of their life. Results from the interviews and focus group discussions laid out the various substance use disorders that are common among patients seeking treatments for SUDs. A lot of factors were revealed to have contributed to the addiction process of each individual, however, patients with mild or severe SUD considered their home environment and peer pressure as the core factors that influenced their abuse. The research also explored the challenges faced by patients who developed SUDs. This chapter discusses the results gathered on the research objectives after analysis was made of the in-depth interviews and focus-group discussions in comparison to the literature. 5.1 Commonly Substances Abused and related to SUD The commonly abused drugs by participants are alcohol, cannabis, cocaine, tramadol, amphetamine, and pethidine. This conforms with a study conducted by (Saapiire et al., 2021) where almost half of the respondents were found to be misusing alcohol, cannabis, cocaine, and alcohol, indicating a high incidence of substance abuse. Aside from alcohol, cigarettes, and marijuana, the majority of young people and adults abuse opioid medications like tramadol, and pethidine and illicit drugs such as cocaine and heroin. Cannabis was 76 University of Ghana http://ugspace.ug.edu.gh revealed to be the substance being abused most by the participants, this confirms a study conducted by Jonhson et al., (2019) where it was also reported that out of all the substances abused, cannabis was found to be the highest substance abused by participants (Johnson et al., 2019). Out of the thirty (30) participants interviewed in this study, fifteen participants are young adults who indicated a lifetime abuse of not a single substance but polysubstance which explained them being diagnosed with severe substance use disorders. However, results indicated that fifteen participants who are adults abused just a single substance in the later part of their lives. Before the study was conducted, this result was anticipated because of the curious nature of adolescents and young adults who are in constant search of a new experiment. The observed increase in the use of multiple substances among adolescents compared to adults in this study is alarming and the frequency of their usage of these substances is a matter of public concern. Most participants (severe SUD) had their first initiation of substance even as early as 13 years, and a few as early as 15 years old while the other respondents (mild SUD) had their first initiation during their adulthood. This can probably explain why the participants who started the abuse early in their adolescence had a severe substance use disorder compared to their counterparts who started abusing substances during adulthood and had mild substance use disorder. This finding is in agreement with Thatcher & Clark (2008) who stated that early childhood abuse of drugs increases the risk for adolescent alcohol use disorders and also increases the risk for problematic drug use. A substance use disorder diagnosed is as a response to which particular substances one was abusing. In the case of Ankaful psychiatric hospital patients, since cannabis use was 77 University of Ghana http://ugspace.ug.edu.gh common among the substances abused, many participants were diagnosed with cannabis- induced psychosis which was the first common among participants with severe SUD, followed by multiple substance use psychosis. 5.2 Factors Influencing Substance Abuse The main factors identified in this study to be influencing factors of substance abuse among SUD patients were easy accessibility, curiosity, enhancement of learning and academic performance, lack of awareness, negative home environment, psychological issues, peer pressure, and social acceptance and marketing of substances. The most basic way in which a dangerous environment might influence substance use behaviors is by making it easier to get substances of abuse. When obstacles to acquiring, using, and abusing substances are reduced, substances are easily available, promoting substance use initiation and potential abuse. This study pointed to easy accessibility of alcohol and tobacco due to the density of alcohol and tobacco outlets. The two groups of participants (mild and severe SUD) stated that the availability and ease of access to certain drugs, as well as their engagement in other drugs and drug information, motivated them to try new substances, which often lead to regular usage and, in some cases, dependence on the drugs. This goes in line with the assertion of (Kasundu et al., 2012; Lipperman-Kreda et al., 2012) which suggests that the presence, closeness, and density of alcohol outlets such as stores or bars selling liquor, wine, and beer are linked to higher alcohol-related mortality and abuse among teenagers and adults. Adding to the easy accessibility of substances, the lack of awareness of the negative effects of substance abuse on the human body is one key factor that needs to be addressed so far as substance abuse is concerned. This finding goes in line with a finding of study conducted by Birhanu et al., (2014) which concluded that a 78 University of Ghana http://ugspace.ug.edu.gh low perceived risk of substance use is more strongly associated with the use of alcohol and cigarettes (Birhanu et al., 2014). The study also found out that curiosity is one of the factors that influenced the abuse of substances in participants with severe SUD, and this group of participants started abusing substances during their adolescence a similar observation was made by participants with mild SUD, who started abusing substances during their adult years. The study revealed a strong association between curiosity and substance abuse and its related disorders, it was discovered that most participants pointed to the desire to experiment with new things as a reason for trying substances the first time. The developmental stage from adolescence to adulthood has been a stage whereby individuals have the urge to explore and try out new. The curiosity and eagerness to experiment with new things in adolescents can easily be explained by some characteristics, such as hyperactivity, novelty-seeking, and impulsivity, which were beneficial to early humans by promoting exploration of the environment and resource acquisition (Jordan & Andersen, 2017), but they have also been linked to substance abuse (Chen et al., 2010). The use of substances in participants is linked to the desire to have a new experiment. One of the key variables that increase drug usage in both youths and adults is their enthusiasm to experiment with drugs to fulfill their curiosity about drugs. Analysis of the two focus group discussions pointed out the importance of self-esteem boost among adolescents and adults. The majority of the participants involved in the study opinionated that they benefitted a lot from confidence after drinking and smoking illicit drugs. The discussions exhibited that adolescents, youths, and adults involve themselves in the abuse of substances just because they believed in the ability of substances to build on their self-confidence, helping them face fearlessly daring situations, especially in social 79 University of Ghana http://ugspace.ug.edu.gh interaction, altercations, feeling positive self-worth, and gaining respect from significant others. Finding the negative home environment of the participant, the study found out that participants who initiated substances in their early adolescence (severe SUD) mentioned negative growth exposure that they had due to their home environment as one factor of influence. On the contrary, adults who started initiation during their adult years mentioned their marital crisis as one of the factors that influenced their abuse. This suggests that irrespective of an individual’s stage in life, the home environment, if not conducive can influence someone’s abuse of substances. This suggests that when it comes to adolescents, it is important to investigate the relationship between children and their parents. The control parents have over their children is crucial to their positive development. The study also posited that participants who started abusing substances during their adolescence were a result of a lack of family history of substance abuse, parental control, lack of involvement, lack of emotional affection, and love from both parents. This finding supports other findings that state that positive parenting features lead to favorable adolescent developmental outcomes, including a slower increase or a faster decrease in problem behaviors (Mensah, 2016; Shek et al., 2020). In a study conducted by Schiff et al., (2014) who posited that parental conflict and violence impact a child's substance use; responses from participants with severe SUD also revealed that growing up in chaotic homes, where there is constant quarreling and conflicts, parents having constant disagreements and parents ending up divorcing has affected them greatly. Meanwhile, as participants with severe SUD look at the home environment as a contributing factor of influence to their abuse, respondents with mild SUD also recognized a negative 80 University of Ghana http://ugspace.ug.edu.gh home environment as a factor. The only difference identified here is that the negative home experience in participants with severe SUD was linked to their parents and extended family, while that of participants with mild SUD was linked to their partners. They later reported that their constant urge to escape from the incessant argument with their significant partner caused them to abuse these substances to release the stress and pain. Participants reported seeking solace among their peers where they are more seen and heard. Concerning the home environment, the participants with mild disorders rather referred to their marital crisis as a factor of influence on their substance abuse. The respondents also mentioned that their abuse of substances was due to pressure from their peers. From rejection and lack of affection from home, they turn to seek solace and find a feeling of belonging to a group of people that they can easily associate with. The finding of the study also threw light on the issue of imitation. It was revealed that most individuals abuse substances because they want to imitate and be liked by their peers. In agreement with Wakoli who concluded in her study that many individuals initiated substance abuse because of modeling and imitation (Wakoli, 2018). About the findings, it was concluded participants that social media advertisements and social marketing of substances had negatively affected them. The study noted that the showcasing of celebrities using substances and the media’s portrayal of substances in movies had reinforced the use and curiosity of participants so far as the abuse of substances is concerned 81 University of Ghana http://ugspace.ug.edu.gh 5.3 Challenges Faced by SUD Patients Although there is a dearth of literature when it comes to challenges faced by patients with substance use disorders. Results from the study showed several challenges faced by individuals dealing with substance abuse and who developed substance use disorder. It was identified stigmatization is a barrier to the treatment and recovery of individuals suffering from substance use disorders. The results of the study also identified that many participants with mild SUD and severe SUD have been stigmatized by their peers, families, and their society ever since their abuse became problematic. Most often, society creates a stereotype around SUD patients making it quite impossible for individuals to be closer to them and offer help that may be vital to their recovery. Society and the immediate environment also apportion the blame to these patients in that they feel they are responsible for their predicament; they feel is a situation that they could avoid entirely. These results also showed the loss of jobs of many participants as a result of developing the disorder and this occurrence also brought economic challenges into their lives. The loss of respect, insults and social status occurred in most of the participants after developing the disorder in participants with mild SUD. In contrast, participants with severe SUD developed difficulties with their academics and eventually dropped out of school. In both groups of participants, health-related problems and difficult emotional reactions were associated with their abuse. They reported experiencing episodic emotional reactions such as depression, anxiety, loneliness, boredom, a feeling of guilt, and anger. This difficulty in emotions has impeded their relationships with other individuals and loved ones. They also reported that one of the things they consider the challenge is a possible relapse after treatment. They are most concerned about the future turn of events where they get 82 University of Ghana http://ugspace.ug.edu.gh anxious about future experiences that may trigger them to relapse. After reintegration into society following treatment, some issues can easily trigger an individual who may relapse. Looking at the stigmatization and apportion of the blame on individuals suffering from SUD, it is clear that if proper sensitization is not done on the topic, treatment may prove futile. These challenges are pushing various authorities to act at the local level so other individuals may understand issues relating to substance abuse and substance use disorders (SUDs) to enable patients to persevere in their quest to become sober. 83 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS 6.0 Summary of Findings The commonly abused drugs by participants are alcohol, cannabis, cocaine, tramadol, amphetamine, and pethidine. Out of the thirty (30) participants interviewed in this study, fifteen participants are young adults who indicated a lifetime abuse of not a single substance but polysubstance which explained them being diagnosed with severe substance use disorders. However, results indicated that fifteen participants who are adults abused just a single substance in the later part of their lives. The observed increase in the use of multiple substances among adolescents compared to adults in this study is alarming and the frequency of their usage of these substances is a matter of public concern. Most participants (severe SUD) had their first initiation of substance even as early as 13 years, and a few as early as 15 years old while the other respondents (mild SUD) had their first initiation during their adulthood. The main factors identified in this study to be influencing factors of substance abuse among SUD patients were easy accessibility, curiosity, enhancement of learning and academic performance, lack of awareness, negative home environment, psychological issues, peer pressure, and social acceptance and marketing of substances. It was identified stigmatization is a barrier to the treatment and recovery of individuals suffering from substance use disorders. The results of the study also identified that many participants with mild SUD and severe SUD have been stigmatized by their peers, families, and their society ever since their abuse became problematic. 84 University of Ghana http://ugspace.ug.edu.gh 6.1 Conclusion Results from Individual interviews and focus group discussions exposed commonly abused substances and the common substance use disorders diagnosed among the patients of Ankaful Psychiatric Hospital. Factors that influenced the abuse of substances among patients diagnosed with either mild or severe SUD were also explored. The prevalence of polysubstance use among adolescents is alarming. In as much as the country’s younger population are into multiple substance abuse, more focus and attention must be placed on this set of the population by instituting evidence-based health policies and decisions. Prevention and control programs must be implemented. Finally, there is a need for strong collaboration between families, educational institutions, health facilities, local government, and the government to reduce this public health threat. 6.2 Recommendations 6.2.1 Law enforcement by Policy-Makers and Various Stakeholders Several policies need to be reinforced and implemented by the government of Ghana at the national and local levels on substance use. There should be restrictions on tobacco and alcoholic drink advertisements by the Food and Drugs Authority. There can also be an introduction of public smoking bans at the local government level of each district to limit the effect of social acceptance. Restrictions should be placed on adolescents' substance acquisition by the Food and Drugs Authority. 85 University of Ghana http://ugspace.ug.edu.gh Agencies such as the Narcotics Control Board (NACOB), regulating the prohibition of illicit drugs in Ghana should also regulate all the illegal routes or mediums through which these drugs are being trafficked into and out of the Ghanaian system. Based on the findings of this study, addressing substance use disorders as a public health problem instead of criminal justice issues will be more effective. The criminalization of drug abusers by the Narcotics Control Bill should be reduced and focus should be channeled towards financing local governments, NGOs, and health care systems to implement the topic-related campaign to create awareness of the negative effects of substances among the young population. 6.2.2 Liaison Between Scientific Experts and Policymakers Policymakers need to collect data on issues regarding substance abuse and engage scientific experts and researchers who will orient the planning and decision-making of substance policy. This will make policies more effective and Evidence-based. 6.2.3 Future Research In terms of research, the findings of this study could be used by other researchers to look into substance abuse and its effects, substance use disorders, and issues surrounding challenges faced by patients diagnosed with substance use disorders. 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All information provided during this interview will be treated with high confidentiality and will only serve this research purpose. SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS Patient research Identification number: ………….......................................... Diagnosed SUD: …………………………………………………………… Gender: 1. Male ( ) 2. Female ( ) b. Age: …………………………………. c. Your level of education: ………………………………………. d. First initiation of substance ……………………………….. Please Note that substance refers to (alcohol, prescription drugs, or illicit drugs) 1. What was your knowledge of substance before using it? 102 University of Ghana http://ugspace.ug.edu.gh 2. If someone were to tell you about substances and their effects, would you have still used them? 3. What substances were you abusing? 4. Was it easy or difficult for you to get these substances? 5. Where were you getting these substances from? 6. How did you access these substances for the first time? 7. How did you get money to buy these substances? 8. Who introduced you to these substances? 9. Why did you start using these substances? 10. How were you first introduced to these substances? 11. How did your family situation contribute to you abusing these substances? 12. What challenges have you faced ever since you started using these substances? 13. How was your childhood like? 14. How did the marital situation of your parents influence your abuse of these substances? 15. How did your parents’ negligence towards you influence your abuse of these substances? 16. What tragic event (s) have you encountered in your life? 17. How did these tragic events influence your abuse of these substances? 103 University of Ghana http://ugspace.ug.edu.gh 18. How did you feel about adverts for drinks and cigarettes on the media (television, social media platforms)? 19. How did the adverts you see on television contribute to you abusing substances? 20. How did watching people drinking and smoking in movies influence your abuse of drugs? 21. What are the challenges you faced ever since you had this disorder? 104 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: CONSENT FORM SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA CONSENT FORM STUDY TITLE: Exploring substance abuse and substance use disorders in patients receiving treatment at Ankaful psychiatric hospital. PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and all questions satisfactorily explained to me in a language that I understand (English / Fante). I fully understand the contents and any potential implications as well as my right to change my mind (i.e., withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Participant’s identification code……………………………………………………… Participants’ Signature: ……………………... Thumb Print:……………………… Date: ………………………………. INTERPRETERS’ STATEMENT I interpreted the purpose and contents of the Participants’ Information Sheet to the aforenamed participant to the best of my ability in the (Fante) language to his proper understanding. All questions, appropriate clarifications sorted by the participant, and answers were also duly interpreted to his/her satisfaction. 105 University of Ghana http://ugspace.ug.edu.gh Name of Interpreter: ……………………………………………………………………. Signature of Interpreter: …………………………... Thumb Print: ………................. Date: ……………………… Contact Details: STATEMENT OF WITNESS I was present when the purpose and contents of the Participant Information Sheet were read and explained satisfactorily to the participant in the language, he/she understood (English / Fante). I confirm that he/she was allowed to ask questions/seek clarifications and the same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name: ………………………… Signature: …………………………...... Thumb Print:………............................ Date: ……………………… 106 University of Ghana http://ugspace.ug.edu.gh APPENDIX D: GHANA HEALTH SERVICE ETHICAL CLEARANCE 107