SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON SUBSTANCE USE DISORDERS AND REHABILITATION AMONG YOUTH IN GHANA AND EFFECTS ON THE FAMILY BY VICTORIA ESINAM ASSAH-OFFEI (10075035) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY (PHD) DEGREE IN PUBLIC HEALTH OCTOBER, 2022 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I hereby declare that except for references to other people’s work which have been duly acknowledged, this piece of work is my own composition and neither in whole nor in part has this work been presented for the award of a degree in this university or elsewhere. SIGNATURE.. DATE……….20-12-2022……………… Victoria Esinam Assah-Offei (PhD Candidate) SIGNATURE................................................. DATE…………20/12/2022…………………. Professor Richmond Nii Okai Aryeetey (Principal Supervisor) SIGNATURE DATE…………20/12/2022….…………. Dr. Deda Ogum Alangea (Co-Supervisor) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION Dedicated to my dear husband Sampson Assah-Offei for his support, prayers, and encouragement. Then to my dear children, Nana Sam Sedem Assah-Offei and Victoria Naa Ayewa Assah-Offei, for their assistance, understanding and for the motherly deprivation they had to endure whilst undertaking this research, all my other children and my entire family. May the Lord Almighty bless and reward you richly. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT To God be the glory, for, in His time, He has made all things beautiful. I am eternally grateful to Almighty God for making it possible for me to go through this course successfully. It has not been an easy road, but the Lord God Himself has been my strength. I wish to express my profound gratitude to my supervisors. Firstly, to Professor Richmond Nii Okai Aryeetey, then to Dr Deda Ogum Alangea for their encouragement, valuable comments, contributions and guidance, without which, this work would not have taken shape. I am also grateful to my Head of Department, Professor Kwasi Torpey and all Lecturers and Staff of the School of Public Health, University of Ghana, especially Professor Moses Aikins, Professor Julius Fobil, Professor Philip Adongo, Professor Amos Laar, Dr Adom Manu, Dr Duah Dwomoh, Dr Agnes Koto, Dr Mawuli Dzodzomenyo, Dr Emmanuel Asampong, Dr Naa Agyemang, Mr Joseph Aidoo, Mr Samuel Kotei Amon, Mr Solomon Tetteh, Mrs Irene Koomson and Miss Pearl Naa Ayokor Tetteh for their support, guidance and encouragement. Equally, I am grateful to my former supervisor, Professor Richard Adanu and Professor Augustine Ankomah, for their initial support for this work. Finally, I thank all my course mates, friends, and family for their moral support. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT INTRODUCTION Substance use disorders (SUDs) is a chronic, relapsing brain disorder that is characterized by compulsive seeking and use of addictive substances. SUDs among the youth continue to be a global public health concern. Treatment of SUDs places a heavy burden on public health systems. This study assessed the factors associated with substance use disorders and examine the effects and cost burden of SUDs and drug rehabilitation on families in Ghana. METHODS The study used an embedded concurrent mixed-method design. It was conducted among 101 participants drawn from four (4) drug rehabilitation centres in the Greater Accra and Eastern Regions of Ghana, from December 2018 to February 2019. The quantitative component relied on a matched case-control design. One hundred and one (101) cases were enrolled from the only existing rehabilitation centres in Ghana, whereas 303 controls consisted of persons living in the same community as the cases but who had never used substances. A closed-ended questionnaire and semi-structured interview guide were used for face-to-face quantitative and qualitative data collection. Quantitative data were analysed using STATA version 15, and qualitative data were analysed using a thematic approach. The cost burden of substance use rehabilitation was calculated by summing the direct and indirect costs of managing drug users. The student t-test and one-way ANOVA test were used to compare average costs. Bivariate and multivariate analyses were done to test statistical relationships between outcome and observed explanatory variables. Statistical significance was set at a p-value of 0.1%, 1% and 5%. University of Ghana http://ugspace.ug.edu.gh vi RESULTS Multiple logistic regression analysis showed that sex, age, highest educational level, employment status, residential status, and friendship with drug users had a statistically significant association with SUDs. Male participants had 1.5 (95% CI:1.2-2.5, p=0.001) times higher odds of SUDs than female participants. Participants aged above 20 years had lower odds of substance use disorders compared to those aged below 20 years (p<0.01). The estimated average household cost of rehabilitation was GHS 4,445.60 per month. The mean monthly indirect cost incurred by urban substance users (472.1 ± 196.40) was statistically significantly higher (p<0.05) than that of rural substance users (181.2 ± 100.30). Of 101 family members of substance users, 57.4% experienced a high intangible burden. Overall, the mean UNODC standard rehabilitation compliance was 3.0 (±0.0), signifying that the compliance standards at the rehabilitation facilities were inadequate. CONCLUSION Males, rural dwellers and younger age have a higher risk of SUDs. Hence public health strategies must target such vulnerable groups. To reduce the high-cost burden associated with the rehabilitation of substance users, the government and stakeholders must subsidize rehabilitation registration costs which contribute more than half of the economic burden of rehabilitation. KEYWORDS: Substance use disorder, drug abuse, rehabilitation, youth, economic cost, Ghana. University of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENTS DECLARATION ............................................................................................................................ ii DEDICATION ............................................................................................................................... iii ACKNOWLEDGEMENT ............................................................................................................. iv ABSTRACT .................................................................................................................................... v LIST OF TABLES ........................................................................................................................ xii LIST OF FIGURES ..................................................................................................................... xiii LIST OF ABBREVIATIONS ...................................................................................................... xiv CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background of the study ........................................................................................................... 1 1.2 Statement of the Problem .......................................................................................................... 5 1.3 Research Questions ................................................................................................................... 7 1.4 Objectives of the study .............................................................................................................. 7 1.4.1 General objective ........................................................................................................... 7 1.4.2 Specific objectives ......................................................................................................... 7 1.5 Justification ............................................................................................................................... 8 1.6 Organization of the thesis ......................................................................................................... 9 1.7 Conceptual Framework ........................................................................................................... 10 Figure 1.1: Conceptual framework for the experiences and factors associated with substance use disorders ........................................................................................................................................ 10 CHAPTER TWO .......................................................................................................................... 13 LITERATURE REVIEW ............................................................................................................. 13 2.1 Introduction ............................................................................................................................. 13 2.2 Biopsychosocial model of substance use disorder .................................................................. 14 2.3 Prevalence of Substance Use .................................................................................................. 15 2.4. Substance Use Disorders ........................................................................................................ 16 2.5 Factors associated with Substance Use ................................................................................... 18 2.5.1 Intrapersonal and interpersonal factors ........................................................................ 18 2.5.2 Micro-environmental factors ....................................................................................... 22 2.5.3 Macro-environmental factors ....................................................................................... 24 2.6 Effects of drug abuse on the user ............................................................................................ 27 2.6.1 Mental Health ............................................................................................................... 27 2.6.2 Quality of life ............................................................................................................... 28 University of Ghana http://ugspace.ug.edu.gh viii 2.6.3 Fetal and childhood development ................................................................................ 29 2.6.4 Lung health .................................................................................................................. 30 2.6.5 Sexual behavior ............................................................................................................ 30 2.7 Effects of drug abuse on the family ........................................................................................ 31 2.8 Economic Cost of SUDs Rehabilitation ................................................................................. 33 2.9 Experiences of Youth with SUDs in Drug Rehabilitation Centres ......................................... 33 2.10 Treatnet Quality Standards ................................................................................................... 34 2.10.1 Quality of drug treatment services ..................................................................................... 36 2.11 Summary of Systematic Review ........................................................................................... 37 2.11.1 Factors associated with substance abuse .................................................................... 37 2.11.2 Effects of substance use disorders on the user ........................................................... 39 2.11.3 Effects of substance use disorders on the family ....................................................... 39 2.11.4 Quality of drug treatment services ............................................................................. 39 2.12 Gaps in literature ................................................................................................................... 40 CHAPTER THREE ...................................................................................................................... 41 METHODOLOGY ....................................................................................................................... 41 3.0 Introduction ............................................................................................................................. 41 3.1 Philosophical Underpinning of the Study ............................................................................... 41 3.2 Research Approach ................................................................................................................. 42 3.3 Study Design ........................................................................................................................... 42 3.3.1 Study Design for Quantitative ..................................................................................... 43 3.3.2 Study Design for Qualitative Component .................................................................... 43 3.4 Study Area .............................................................................................................................. 44 3.5 Study Population ..................................................................................................................... 44 3.5.1 Cases ............................................................................................................................ 44 Table 3.1: The population of cases of each drug rehabilitation center ......................................... 45 3.5.2 Control ......................................................................................................................... 45 3.6 Criteria for Selection ............................................................................................................... 45 3.6.1 Inclusion Criteria ......................................................................................................... 45 3.6.2 Exclusion Criteria ........................................................................................................ 46 3.7 Sample Size Calculation ......................................................................................................... 46 3.7.1 Sample Size Calculation for Quantitative Study ......................................................... 46 3.7.2 Sample Size Calculation for the Qualitative Study ...................................................... 47 3.8 Sampling Technique ............................................................................................................... 48 University of Ghana http://ugspace.ug.edu.gh ix 3.8.1 Sampling Technique for Quantitative Study ................................................................ 48 Table 3.2: The number of cases sampled from each drug rehabilitation center ........................... 49 3.8.2 Sampling Technique for Qualitative Study .................................................................. 49 3.9 Study Variables for Quantitative Study .................................................................................. 50 Table 3.3: Summary of Variables Used in the Quantitative Study ............................................... 50 Table 3.3: Summary of Variables Used in the Study (Con’t) ....................................................... 51 3.10 Data Collection Methods and Tools ..................................................................................... 52 3.10.1 Quantitative data collection methods and tools ......................................................... 52 3.10.2 Qualitative data collection methods and tools ........................................................... 55 3.11 Quality Control Measure ....................................................................................................... 57 3.11.1 Training of Research Assistants ................................................................................. 58 3.11.2 Pre-Testing and Review of Data Collection Instrument ............................................ 58 3.12 Data Management and Analysis ........................................................................................... 58 3.12.1 Quantitative Data Management and Analysis ............................................................ 58 3.12.2 Qualitative Data Analysis .................................................................................... 63 3.13 Ethical considerations ........................................................................................................... 63 CHAPTER FOUR ......................................................................................................................... 66 RESULTS ..................................................................................................................................... 66 4.1 Socio-demographic characteristics of participants ................................................................. 66 Table 4.1: Socio-demographic characteristics of study participants ............................................ 67 4.2 Household characteristics of study participants ...................................................................... 68 Table 4.2: Household characteristics of study participants .......................................................... 69 4.3 Social and environmental characteristics of study participants .............................................. 70 Table 4.3: Social and environmental characteristics of study participants ................................... 71 4.4 Relationship between socio-demographic characteristics and substance use disorders among study participants .......................................................................................................................... 72 Table 4.4: Relationship between socio-demographic factors and substance use disorders among study participants .......................................................................................................................... 75 4.5 Relationship between household characteristics and substance use disorders among study participants .................................................................................................................................... 76 Table 4.5: Relationship between household characteristics and substance use disorders among study participants .......................................................................................................................... 77 4.6 Relationship between social and environmental factors and substance use disorders among study participants .......................................................................................................................... 78 Table 4.6: Relationship between social and environmental factors and substance use disorders among study participants .............................................................................................................. 79 University of Ghana http://ugspace.ug.edu.gh x 4.7 Multiple logistic regression analysis of factors associated substance use disorders among study participants .................................................................................................................................... 80 Table 4.7: Multiple Logistic Regression Analysis of factors associated with substance use disorders among youths at the drug rehabilitation centre ............................................................. 82 Table 4.7: Multiple Logistic Regression Analysis of factors associated with substance use disorders among youths at the drug rehabilitation center (Con’t) ................................................ 83 4.8 Cost of SUDs rehabilitation .................................................................................................... 84 4.8.1 Direct cost of SUDs rehabilitation ............................................................................... 84 4.8.2 Indirect cost of drug addiction rehabilitation ............................................................... 84 4.8.3 Differences in the mean rehabilitation cost across different socio-demographic characteristics of study participants ...................................................................................... 85 Table 4.8 Direct and indirect costs ............................................................................................... 86 Table 4.9: Differences in the mean rehabilitation cost across different socio-demographic characteristics of study participants .............................................................................................. 87 4.9 Sensitivity analysis of the cost of drug addiction rehabilitation ............................................. 87 Table 4.10: Sensitivity analysis of the cost of drug addiction rehabilitation ................................ 89 4.10 Compliance of Drug Rehabilitation Centres in Ghana to UNODC standard ....................... 90 Table 4.11 Compliance of Drug Rehabilitation in Ghana to UNODC Guidelines ....................... 91 4.11 Experiences of the youth who are in rehabilitation for substance use disorders and their families in Ghana .......................................................................................................................... 92 4.11.1 Background characteristics of qualitative study participants ..................................... 92 Table 4.12: Summary characteristics of individuals in rehabilitation in the four-drug rehabilitation facilities ......................................................................................................................................... 92 4.12 The experiences of the youth who are in rehabilitation for substance use disorders. ........... 93 Table 4.13: Summary of Experiences of using drug substances and being at the drug rehabilitation center ............................................................................................................................................. 94 4.12.1 Drivers of drug addiction ........................................................................................... 94 CHAPTER FIVE ........................................................................................................................ 102 DISCUSSION ............................................................................................................................. 102 5.1 Introduction ........................................................................................................................... 102 5.2 Economic cost associated with drug rehabilitation on persons with SUDs and their families ..................................................................................................................................................... 113 5.3 Experiences of youth with SUDs in drug rehabilitation and their families .......................... 116 5.4 Compliance of Drug rehabilitation Centres in Ghana to UNODC Guidelines ..................... 118 5.5 Strengths of the study ............................................................................................................ 122 5.6 Limitations ............................................................................................................................ 123 5.7 Contributions to knowledge .................................................................................................. 123 University of Ghana http://ugspace.ug.edu.gh xi CHAPTER SIX ........................................................................................................................... 125 CONCLUSION AND RECOMMENDATIONS ....................................................................... 125 6.1 Conclusion ............................................................................................................................ 125 6.2 Recommendations ................................................................................................................. 125 REFERENCES ........................................................................................................................... 128 APPENDIX-I (QUESTIONNAIRE) .......................................................................................... 141 Appendix 2: Information Sheet for Focus Groups/ Stakeholders /Residents /Family Members 152 Appendix 3 – Informed Consent Form for Focus Group Discussions and In-depth Interviews 154 Appendix 4 - Ethical Approval ................................................................................................... 155 University of Ghana http://ugspace.ug.edu.gh xii LIST OF TABLES Table 3.1: The population of cases of each drug rehabilitation center ......................................... 45 Table 3.2: The number of cases sampled from each drug rehabilitation center ........................... 49 Table 3.3: Summary of Variables Used in the Quantitative Study ............................................... 50 Table 4.1: Socio-demographic characteristics of study participants ............................................ 67 Table 4.2: Household characteristics of study participants .......................................................... 69 Table 4.3: Social and environmental characteristics of study participants ................................... 71 Table 4.4: Relationship between socio-demographic factors and substance use disorders among study participants .......................................................................................................................... 75 Table 4.5: Relationship between household characteristics and substance use disorders among study participants .......................................................................................................................... 77 Table 4.6: Relationship between social and environmental factors and substance use disorders among study participants .............................................................................................................. 79 Table 4.7: Multiple Logistic Regression Analysis of factors associated with substance use disorders among youths at the drug rehabilitation center ............................................................. 82 Table 4.8 Direct and indirect costs ............................................................................................... 86 Table 4.9: Differences in the mean rehabilitation cost across different socio-demographic characteristics of study participants .............................................................................................. 87 Table 4.10: Sensitivity analysis of the cost of drug addiction rehabilitation ................................ 89 Table 4.11 Compliance of Drug Rehabilitation in Ghana to UNODC Guidelines ....................... 91 Table 4.12: Summary characteristics of individuals in rehabilitation in the four-drug rehabilitation facilities ......................................................................................................................................... 92 Table 4.13: Summary of Experiences of using drug substances and being at the drug rehabilitation center ............................................................................................................................................. 94 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF FIGURES Figure 1.1: Conceptual framework for the experiences and factors associated with substance use disorders ........................................................................................................................................ 10 University of Ghana http://ugspace.ug.edu.gh xiv LIST OF ABBREVIATIONS DALYs – disability-adjusted life years DSM – Diagnostic and Statistical Manual of Mental Disorders HCV – hepatitis C virus HIV – Human Immunodeficiency Virus ICD – International Statistical Classification of Diseases MeSH – Medical Subject Heading PCL – PTSD Checklist PTSD – Post-Traumatic Stress Disorder PWID – People Who Inject Drugs QOL – Quality of Life SDQ – Strength and Difficulties Questionnaire SES – Socio-Economic Status SUD – Substance Use Disorder UNODC – United Nations Office on Drugs and Crime WHO – World Health Organization WHOQOL-World Health Organization Quality of Life University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background of the study Substance use disorders (SUDs) among the youth continue to be a public health concern globally (Duperrouzel et al., 2018; Coffey & Patton, 2016; James, Smyth & Apantaku-Olajide, 2013). It is a chronic, relapsing brain disorder that is characterized by the compulsive seeking and use of addictive substances, including but not limited to alcohol and mood-altering substances (Kumar, Dangi, & Pawar, 2019; National Institute on Drug Abuse [NIDA], 2019). Some mood-altering substances include cocaine, cannabis, opioids, opiates, and synthetic drugs such as amphetamines (World Drug Report, 2018). The addictive substances often result in adverse consequences on the individual, family, and society's psychological, social, and physical functioning (NIDA, 2019). Some of the consequences of substance use on the individual are expressed as an intense and, sometimes, uncontrollable craving, along with compulsive seeking of the drug and abuse that persists although it results in harmful consequences (Rich, 2011). According to Wani (2016), it changes the core structure of the brain of the addicted person and how it functions. It causes mental health illnesses such as depression, bipolar mood disorder, anxiety, paranoia- excessive suspicion, aggressive behaviour, and hallucination (Corazza et al., 2014). This effect could be long-lasting and can lead to multiple harmful self-destructive behaviours. Substance use disorders also lead to legal and financial consequences and health risks such as human immunodeficiency virus (HIV) infection, hepatitis C virus (HCV) infection, and cardiovascular diseases (NIDA, 2019). Substance use has adverse health consequences on the youth and has a significant impact on social University of Ghana http://ugspace.ug.edu.gh 2 dimensions such as academic performance and an increase in the incidence of school dropout (World Health Organization [WHO], 2011; Aaron et al., 1999). The effects of substance use and SUDs on the family and community include traumatic childhood experiences, especially by children of persons with SUDs, which contribute to addictive and criminal offences, comprising theft, burglary, sex work, shoplifting and affect family relationships (Daley, 2014). Families of persons with SUDs suffer from various forms of disruptions such as marital breakdown, loss of custody of children, stigma, emotional withdrawal, guilt and shame, loss of employment, financial instability, physical and psychological abuse, depression and ill- health (Schafer, 2011; Daley, 2014; Nimtz, 2014). Additionally, families experience unmet developmental needs, impaired attachment, legal problems, emotional distress and being a victim of violence (Lander, Howsare, & Marilyn, 2013). Substance use problems have been increasing gradually since 2006; thus, it remains an important global issue (United Nations Office on Drugs and Crime [UNODC], 2019). Globally, the United Nations Office on Drugs and Crime report states that an estimated 255 million people (5.3%) abused illicit drugs, 25 million are regarded as substance abusers, and at least 15.3 million persons have substance use disorders (World Drug Report, 2018). The prevalence of substance use among youth in Sub-Saharan Africa region ranges between 20.9% and 55.5% (Olawole et al., 2018; Jatau et al., 2021). The prevalence of substance was 20.9% in Nigeria (Jatau et al., 2021), was 7.4% in Egypt (Amin, Elnagdi, & Amer, 2019), and was 47.9% in Ethiopia (Birhanu et al., 2014). Substance use among the youth is more prevalent in developing countries than in developed countries (Salwan & Katz, 2014) and people living in low-income- University of Ghana http://ugspace.ug.edu.gh 3 and middle-income countries (Suasnabar & Walters, 2020). The high prevalence of substance use is due to poverty, negative peer influences, broken homes, and lack of parental involvement and social support (Chesang, 2013; Jorge et al., 2018). The rise in global drug menace compelled the United Nations General Assembly to convene a Special Session (UNGASS) in 2016 ahead of its scheduled date of 2019 to achieve a significant reduction in the world drug problem (UNGASS, 2016). Substance use differs by sex and age. For instance, men are reported to use substances more than women (Fawzy et al., 2012; Rabie et al., 2020). Risk factors identified to influence substance use are biological or genetic predispositon such as aggressive behaviour in childhood (Zucker et al., 2008; Grant et al., 2001), sensitivity to illicit drugs, low peer refusal skills (Grant et al., 2001; Guo et al., 2001; Brook et al., 1990), socio-demographic characteristics such as age, gender (Becker & Hu, 2008), developmental stage (Gallimberti et al., 2015), environmental risk factors such as lack of parental supervision (Hill et al., 2016; Zucker et al., 2008), broken home, poor academic performance (NIDA, 2003), drug experimentation (Zucker et al., 2008; Sher & Rutledge, 2007; Chassin et al., 2002), availability of drugs (Sher & Rutledge, 2007; Brook et al., 1999), and community poverty (Hawkins et al., 1995; Herting & Guest, 1985). Treatment of substance use disorders has placed a heavy burden on public health systems. Only one out of every six persons with substance use disorders has access to treatment globally (World Drug Report, 2018). The global annual number of preventable drug-related deaths was estimated as 187,100 in 2018, often due to an overdose and lack of access to treatment (World Drug Report, 2018). Many countries, including Ghana, have large shortfalls in providing substance use treatment services (World Drug Report, 2018). University of Ghana http://ugspace.ug.edu.gh 4 Substance use treatment services such as drug addict rehabilitation are employed to manage drug addicts. Drug addiction rehabilitation is the process of using medical and psychotherapeutic treatment for managing dependency on addictive substances such as alcohol, prescription drugs, and narcotic drugs such as heroin and amphetamines. (Marlatt & Donovan, 2012). The overall objective of a well-established drug rehabilitation service is to enable the client to confront drug addiction, help drug addicts prepare to re-enter society, cease drug abuse, and avoid the overall negative impact of drug addiction (WHO, 2014). The quality of the rehabilitation facilities is evaluated using the international standards for the treatment of drug use disorders developed by UNODC. This is a standard tool to support nations in their efforts to develop an effective, evidence-based and ethical treatment for drug use disorders. The standards are intended for all those involved in the policy development, planning, funding, delivery, monitoring and evaluation of treatment services and interventions for drug use disorders (WHO, 2020). However, there are limited drug addiction treatment facilities in the world. Only 1.7 health service beds per 100,000 population are available for rehabilitation globally (WHO, 2014). A report by the UNODC in 2018 revealed that only one in six drug addicts worldwide receive rehabilitation treatment annually (World Drug Report, 2018). Assessment of substance use disorders among the youth has become important because it is vital to understand the impact of substance use disorders on their family and community and whether their visit to rehabilitation has improved their quality of life. Research into substance use disorders among the youth remains a grey area in sub-Saharan Africa, specifically in Ghana, hence, the need to study the phenomenon and its related factors among the youth in Ghana. University of Ghana http://ugspace.ug.edu.gh 5 1.2 Statement of the Problem Substance use disorder such as alcohol and illicit drug addiction is a global public health concern (Deenhardt et al., 2008). The advancement of drug addiction rehabilitation has helped patients overcome substance use disorders, re-enter society, and avoid the overall negative impact of drug addiction on the family and society (WHO, 2014). However, youths addicted to substance use suffer from mental health illnesses such as depression, bipolar mood disorders, anxiety, paranoia- excessive suspicion, aggressive behaviour, and hallucination (Corazza et al., 2014). Harmful use of substances by the youth also results in poor academic performance, increased school dropout, co-morbidity burden, decreased life expectancy, decreased quality of life, and increased mortality rate (Schulte & Hser, 2013; Ghoreishi et al., 2017; UNODC, 2018). SUDs influence the individual and affect the family and community (Rowe, 2012; Lander, Howsare, & Byrne, 2013). For instance, substance use disorders result in a rise in juvenile delinquency and financial burden on the family (Kumpfer, 2014). Addiction to alcohol and illicit drugs, especially among the youth, has become a public health concern in Ghana ( Appiah et al., 2017; Adzrago, 2018). The prevalence of substance use, such as alcohol among the youth in Ghana, was 39.3% (Doku, Koivusilta, & Rimpelä, 2012). According to the World Drug Report in 2017, Ghana is placed at the 14th position globally for cocaine use; in addition, Ghana is considered a cannabis production hub (Lucia, 2019; Domestic Drug Consumption in Ghana). Even though addiction to alcohol and illicit drugs is common, only a few drug rehabilitation facilities are available to treat persons with substance use disorders (Kabore et al., 2019). These facilities do not provide addiction support services for relapse prevention (De Lugo, 2019). Some University of Ghana http://ugspace.ug.edu.gh 6 of these drug rehabilitation centres are situated inside psychiatric institutions that pose stigma issues for persons with substance use disorders and their families (Appiah et al., 2017). The private-owned drug rehabilitation centres, such as the non-governmental funded by faith-based organizations in Ghana, charge high fees for rehabilitation services and apply religious approaches to drug rehabilitation which imposes restrictions on the type of patients they admit (Appiah et al., 2017). Although the evidence on substance use disorders is well documented (Duperrouzel et al., 2018; National Institute of Drug Alcohol, 2019; World Drug Report, 2018; Lander et al., 2013)., there is limited evidence on the risk factors influencing substance use disorders, the economic burden of drug addiction on their families, experiences of the youth who are most at risk of becoming addicts and those receiving treatment at the drug rehabilitation facilities. Also, most of the studies conducted on substance use disorders in Ghana were on men only (Andoh-Arthur et al., 2020), adolescents aged 15-19 years (Doku, Koivusilta, & Rimpelä, 2012; Addo et al., 2016; Asante & Kugbey, 2019), street children (Asante & Nefale, 2021) and those in senior secondary schools (Adu-Mireku, 2003; Nkyi, 2014). There is a dearth of studies on the youth and those receiving treatment for drug addiction or substance use disorders at the drug rehabilitation centres in Ghana from age 15 to 35 years. There is limited evidence of the quality of existing drug rehabilitation in Ghana. Therefore, there is the need for evaluation of rehabilitation facilities in Ghana, based on the United Nations Office on Drug and Crime (UNODC) guideline. In this light, the research seeks to assess substance use disorders and their associated factors and the effects of substance use disorders and rehabilitation on families in Ghana. This study is designed to inform future interventions, such as creating public University of Ghana http://ugspace.ug.edu.gh 7 awareness of the health implications of drug abuse to curb the drug addiction menace in Ghana. The findings of this study would also be useful for developing family prevention of drug addiction programmes in the form of multi-dimensional family therapy and individual cognitive behavioural therapy. 1.3 Research Questions The following questions guided the study: i. What factors are associated with substance use disorders among Ghanaian youth? ii. What is the economic cost of rehabilitation from substance use disorders on drug addicts and their families in Ghana? iii. What are the experiences of the youth who are in rehabilitation for substance use disorders and their families in Ghana? iv. How well do drug rehabilitation centers in Ghana comply with the United Nations Office on Drug and Crime (UNODC) guideline? 1.4 Objectives of the study 1.4.1 General objective The general objective of the study was to determine factors associated with substance use disorders among Ghanaian youth and families and their rehabilitation experience 1.4.2 Specific objectives The specific objectives of this study were to; 1. Determine the factors associated with substance use disorders among Ghanaian youth. University of Ghana http://ugspace.ug.edu.gh 8 2. Describe the economic cost of rehabilitation from substance use disorders on drug addicts and their families in Ghana. 3. Describe the experiences of the youth who are in rehabilitation for substance use disorders and their families in Ghana. 4. Determine compliance of drug rehabilitation centers in Ghana to the United Nations Office on Drug and Crime (UNODC) guideline. 1.5 Justification There are no studies that focused on the risk factors of SUDs, together with experiences of youths at the rehabilitation centres and economic burden on families. Therefore, the current study will provide information on Risk factors of SUDs in Ghana, Economic cost of rehabilitation in Ghana, Experiences of the youth with SUDs and families in rehabilitation and Quality standards of SUD rehabilitations in Ghana A few studies provided some information on SUDs in Ghana: experiences of people who are in rehabilitation for substance use disorders (Adzrago et al., 2018); there are limited studies on the factors associated with substance use disorders among youth in Ghana (Kabore et al., 2019). This study, therefore, contributes to exploring the experiences of the youth who are in rehabilitation for substance use disorders and their families in Ghana. Knowing the experiences of the youth in rehabilitation for substance use disorders will enhance the development of training materials and provide mentoring opportunities for drug rehabilitation practitioners on how to manage drug rehabilitation related issues. Also, knowing the experiences of youth would aid the community, the health sector, particularly drug rehabilitation centres, non-governmental organizations, and the government to formulate strategic measures that would help minimize substance use disorders in University of Ghana http://ugspace.ug.edu.gh 9 the communities. The findings of this study will also help persons with SUDs undergoing treatment at the rehabilitation centres adhere to counselling therapy to improve their self-esteem and enable them to have positive coping skills for handling stress and mental health issues. Knowing how drug rehabilitation centres in Ghana comply with the United Nations Office on Drug and Crime (UNODC) guideline would be used by the Government, including the Ministry of Health and the Ghana Health Service, to improve and promote adherence to international standards of care for drug rehabilitation practitioners. It will also provide evidence for policy direction on the need to strengthen existing drug rehabilitation centres to provide comprehensive care for persons with substance SUDs. 1.6 Organization of the thesis The thesis is organized into five main chapters. Chapter one introduces the research background, the statement of the problem, the research objectives and research questions, the significance of the study, and how the study is organized. Chapter two presents a literature review of theoretical and empirical studies to provide a theoretical grounding for the study. Chapter three entails the methodology by detailing the research process, the data collection method, an in-depth interview guide developments and methods and modes of the interviews conducted. Chapter four presents the data analysis results from documentations, field interviews, and surveys. It also discusses the main findings of the research. Chapter five, the final chapter, presents a summary of the empirical outcomes, the conclusions and recommendations of the study. University of Ghana http://ugspace.ug.edu.gh 10 1.7 Conceptual Framework Figure 1.1: Conceptual framework for the experiences and factors associated with substance use disorders. The model is based on Andersen and Newman's healthcare utilization propounded in 1973, and the Health Belief Model (HBM) propounded in 1991. The Andersen and Newman healthcare utilization model proposes that utilization of health services is determined by three factors, namely, predisposing factors, enabling factors, and need factors. The predisposing factors are the socio-demographic, household characteristics, social and Socio-demographic characteristics • Age • Sex • Highest level of education • Employment status • Marital status • Religious affiliation • Number of children • Family size • Current residence Household characteristics • Household size • Person lived with until age 15 • A person currently living with • Life status of father • Father’s highest educational level • Life status of mother • Mother’s highest educational level • Parent’s economic status Social and environmental characteristics • Control over when and where to go at night • Control over what friends to keep • Control over whether or not to use drugs • Control over whether or not to go to work or school • Control over whether or not to drink alcoholic beverages • Control over how to spend money • Strictness of guardian • Relationship with parents • Strength of family ties • Any family member who uses drugs • Any friend who uses drugs • Any area in the vicinity where hard drugs are traded. Substance Use Disorders Experience of people at the rehabilitation centre with SUD • drivers of SUD such as peer influence, loss of loved ones, curiosity, broken home, and pain and anxiety Economic cost associated with rehabilitation from SUD on person with SUD and family University of Ghana http://ugspace.ug.edu.gh 11 environmental factors such as age, sex, the highest level of education, employment status, marital status, religious affiliation, etc. that are associated with SUD. The enabling factors include caregiver support and physical access to the rehabilitation that facilitate access to health services. Need factors comprise the perceived and/or actual need for health services (Li et al., 2016). This socio-demographic characteristics, household characteristics, social and environmental factors, and its association with substance use disorders among the youth in rehabilitation are presented in Figure 1.1. The socio-demographic characteristics are age, sex, the highest level of education, employment status, marital status, religious affiliation, number of children, family size, and current residence. Generally, socio-demographic characteristics such as employment status are associated with SUDs (Teixidó-Compañó et al., 2018. Also, the association between SUD and socio-demographic characteristics may be a reflection of the higher substance use behaviour among males globally (Gallimberti et al., 2015; Birhanu et al., 2014). According to Fothergill et al. (2012), persons with postgraduate education are less likely to become drug addicts than middle school leavers. The social and environmental values are: control over when and where to go at night, control over what friends to keep, control over whether or not to use drugs, control over whether or not to go to work or school, control over whether or not to drink alcoholic beverages, control over how to spend money, the strictness of guardian, relationship with parents, the strength of family ties, any family member who uses drugs, any friend who uses drugs, and any area in the vicinity where hard drugs are traded. Social and environmental characteristics, such as any area in the vicinity where substances were sold, influence youth to engage in substance use (Kabore et al., 2019). According University of Ghana http://ugspace.ug.edu.gh 12 to Kabore et al. (2019), areas such as slum communities sell substances at low prices and make them available for use. University of Ghana http://ugspace.ug.edu.gh 13 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents a review of the literature in relation to the study objectives. The themes covered in this chapter are the introduction, patterns of substance use, understanding the problem, factors associated with substance use disorders (SUDs), effects of SUDs on the user, effects of SUDs on the family and gaps in the literature. Substance use remains highly prevalent among adolescents and young adults. Different combinations of poly-drug use and the ever-changing compositions of newly synthesized drugs may make it difficult to catch up in terms of determining the correlates of substance use and their effects on users. It is estimated that only 16% of people with SUDs are in treatment; hence, studies involving people in treatment may not give a comprehensive understanding of the questions being asked. Prisons are high-risk environments for infectious disease and drug use (UNODC, 2016). Allwood (2012) declared that an in-depth evaluation of the literature permits researchers to generate suitable research questions and techniques. The research articles included in the review were obtained through the definition of the key terms, search words, fields and exclusion and inclusion criteria. The search parameters included research papers published in recognized peer reviewed journals, written in English with a named author and full-text articles. The researchers searched for the key phrase, ‘determinants of SUDs’. The search was limited to the titles and keywords of the research articles. The search was not limited to any journal to ensure that the search was comprehensive (Briner et al., 2009). The major search engine from online research databases for most of the articles used were PubMed, JSTOR and Sage. The following databases were finally used based on the responses from the search process – Elsevier, Springer, Taylor and University of Ghana http://ugspace.ug.edu.gh 14 Francis, Wiley, BMC, PLOS ONE, and Pub Med. Keywords include “substance use”, “substance use disorders”, "lifestyle factors and substance use disorders" "peer factors and substance use disorders" and "socio-demographic factors and substance use disorders" published in the English language were used. Boolean operators such as "AND" and "OR" were employed in combination to discover a wider scope of literature in the study area. Search terms include (Socio-demographic Use OR Lifestyle factors) AND (substance use disorders). The articles were scanned and assessed before chosen for the review. The criteria employed for selection comprises publication status, evidence, reference, and whether it was reviewed. The review is organized according to the specific objectives. 2.2 Biopsychosocial model of substance use disorder The biopsychosocial model of addiction posits that biological/genetic, psychological, and sociocultural factors contribute to substance use. This model emerged in response to criticisms of the biomedical model, which has historically dominated the field of addiction studies. The traditional biomedical model was developed and is espoused by medical scientists for the study of disease, and its proponents also view addiction as a chronically relapsing brain disease with a genetic/biochemical cause. The biomedical or disease model of addiction views addiction as the manifestation of disturbances in measurable biochemical or neurophysiological processes in the afflicted individual. The biopsychosocial model shows that the biological, genetic, personality, psychological, cognitive, social, cultural, and environmental factors interact to produce the substance use disorder. The interaction of these factors to produce substance use problems is the core tenet of the biopsychosocial model of addiction. University of Ghana http://ugspace.ug.edu.gh 15 2.3 Prevalence of Substance Use The crucial stage of adolescence through to young adulthood is characterized by a rise in experimentation and the use of substances (Gray & Squeglia, 2018; Degenhardt et al., 2016). Substance use is the continuous use of substances, illicit drugs, or the misuse of medicines or over- the-bench drugs with negative consequences (Panthee et al., 2017). Substance use can be grouped into illicit drugs and alcohol. According to Hall et al. (2008), illicit drugs are those for nonmedical use that are banned by national or international laws. Examples of illicit drugs are psychoactive drugs such as stimulants, sedatives, narcotics, hallucinogens, opioids, and cannabis. Psychoactive drugs are non-medical self-administered substances to offer mood-changing effects, intoxication, or altered self-image despite the knowledge of their adverse reactions (American Psychiatric Association, 1980). Examples of opioids are morphine, fentanyl, hydrocodone, codeine, oxycodone, and heroin; stimulants are amphetamines, methamphetamines, cocaine, caffeine, nicotine, ephedrine; inhalants are paint thinner and certain glues; hallucinogens are lysergic acid diethylamide (LSD), phencyclidine (PCP), psilocybin mushrooms, peyote, or mescaline; examples of cannabis are marijuana and synthetic cannabinoids (Gámez-Guadix et al., 2013; Gureje et al., 2007, Grossman, 2005). The commonly used substances among the youths in Ghana are cigarettes, alcohol, marijuana, heroin, cannabis, amphetamines, and cocaine (Aboagye et al., 2021; Oppong- Asante, 2019; Asante, Meyer-Weitz, & Petersen, 2014; Doku, 2012). The prevalence of the usage of illicit drugs was 5.6% worldwide (WHO, 2018). Particularly, the prevalence of substance use was 50.0% in Iran (Khezri et al., 2020). In the sub-Saharan African region, the overall prevalence of substance use was 41.6%, with the highest rate of 55.5% being in Central Africa Republic (Ogundipe et al., 2018). Particularly, the prevalence of substance use among the youth was 52.5% in Rwanda (Kanyoni, Gishoma, & Ndahindwa, 2015), 27.5% in the University of Ghana http://ugspace.ug.edu.gh 16 University of Uyo, Nigeria (Johnson et al., 2017), 47.9% in schools in Woreta town, Ethiopia, 20% in the University of Nairobi, Kenya (Musyoka et al., 2020), and 6.5% in Mansoura University in Egypt (Khafagy, Gomaa, & Elwasify, 2021). A study in Ghana showed that 12% and 16% of the youth are engaged in alcohol and marijuana, respectively (Asante, Meyer-Weitz, & Petersen, 2014). Also, Aboagye et al. (2021) found that 39.5% of tertiary students are engaged in alcohol consumption in Hohoe Municipality in Ghana. The adverse effects of substance use may be expressed at various levels, such as individuals, families, and communities. The effects of these problems have various dimensions comprising mental health issues, physical health, and economic consequences (Das et al., 2016; Gutierrez & Sher, 2015). People involved in continuous substance use are at risk of fatal and non-fatal overdoses (Mokdad et al., 2016). They also suffer from multiple disease burdens, and many have physical and mental comorbidities such as personality disorders, psychotic and affective disorders and socio-economic difficulties (Mueser et al., 2012; Ross & Peselow, 2012). Further, it leads to psychiatric disorders such as depressive symptoms, lethargy, insomnia, and hopelessness (Bond et al., 2005; Volkow & Li, 2005). Injection of substance use has resulted in a high prevalence of human immunodeficiency virus (HIV) infections, hepatitis C virus (HCV), and bacterial abscesses (Aas et al., 2020; Gamarel et al., 2018). According to Nyongesa et al. (2021), people in substance abuse mostly have unstable housing situations, disrupted family, social relationships, and unemployment. 2.4. Substance Use Disorders Substance use disorders (SUDs) is the continuous use of substances despite substantial harm and adverse consequences (Verdejo-García, Lawrence, & Clark, 2008). It describes both illicit or University of Ghana http://ugspace.ug.edu.gh 17 illegal substances and the misuse of legal substances like alcohol, nicotine, or prescription drugs (Khalsa, 2021; Alblooshi et al., 2016). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), outlines eleven symptoms of SUDs. These comprise: 1. Having a persistent wish to stop using the substance and/or continuously trying to reduce or control substance use. 2. Continuing to use the substances despite knowing that a physical or psychological health issue was likely caused or worsened by the substance. 3. Using the substance in larger amounts or over a long period than originally intended. 4. Exhibiting withdrawal symptoms when not using the substance. 5. Spending a significant amount of time trying to obtain the substance, use it, or recover from using it. 6. Stopping or decreasing social, work-related, or recreational activities due to substance use. 7. Building up a tolerance, where a larger amount of the substance is needed to experience an effect. 8. Having a strong urge to use the substance. 9. Continuing to use even when it causes an inability to fulfill work, school, or home-related responsibilities. 10. Continuing to use the substance even when it causes interpersonal problems or makes them worse. 11. Continuing to use the substance even in risky or physically dangerous situations. University of Ghana http://ugspace.ug.edu.gh 18 Persons with SUDs are at risk of adverse health effects such as increased drug and non-drug related mortality (McDonald et al., 2021; Gao, Robertson, & Bird, 2019; Hakansson & Berglund, 2013), physical morbidities comprising chronic obstructive pulmonary disease, hepatitis C, cancer, and self-reported somatic symptoms (Medved et al., 2020), and underutilization of healthcare services (Swendsen et al., 2012). Persons with SUDs also face stigma and discrimination. According to Kulesza et al. (2017), Kulesza, Larimer, and Rao (2013), and Van Boekel et al. (2013), adverse outcomes such as reduced wellbeing, self-esteem and self-efficacy, prevent healthcare-seeking and reduced compliance. 2.5 Factors associated with Substance Use A host of risk factors come to play in influencing substance use or drug abuse. The influence of some of these risk factors depends on the individual's developmental stage. Several permutations of these factors interact to increase or lessen the risk of substance use. This review presents a modified version of the three main domains (Rhodes et al., 2003) under which these risk factors can be grouped. They include intrapersonal/interpersonal, micro-environmental and macro- environmental factors. 2.5.1 Intrapersonal and interpersonal factors Factors falling under this domain include intrapersonal/endogenous and interpersonal /exogenous traits that may determine the extent to which one would be involved in drug use. Some include socio-demographic characteristics, personality traits, physiological pain, mental illness and cognitive performance. University of Ghana http://ugspace.ug.edu.gh 19 2.5.1.1 Socio-demographic characteristics Sex: Analysis of the 2002-2004 data on the Canadian Youth Smoking Survey showed that male youth were 45% less likely to have ever smoked a whole cigarette compared to female youth (Leatherdale, Hammond, & Ahmed, 2008), whiles Palamar, Kiang, and Halkitis (2014) reported no gender differences in the use of amphetamines, opioids, cocaine and marijuana. All other studies in this review reported otherwise. Men were 2.01 (95% CI, 1.93-2.09) times more likely to be alcohol abusers (Gauffin, Hemmingsson, & Hjern, 2013), 1.96 (95% CI, 1.43-2.69) and 1.27 (1.21-1.34) times more likely to report lifetime marijuana and inhalant use (Hodge, Marsiglia, & Nieri, 2011) compared to females. In another study, being male had a positive association with using marijuana and pro-drug personal norms, although not significant (Parsai, Marsiglia, & Kulis, 2010). Also, the risk of men having alcohol use disorders relative to abstaining from alcohol was 1.7 times that of women. Men were also less likely to be non-disordered drinkers than women (Schulenberg et al., 2015). Age: A study in Nigeria found that youth who were 15 years or below were less likely to use substances (OR 0.61, 95% CI 0.44-0.88) (Atilola et al., 2013). Leatherdale et al. (2008) also reported the mean age of first use of alcohol, marijuana and cigarette to be 11.6, 11.5 and 12.6 years, respectively. Schulenberg et al. (2015) found that binge drinkers, current smokers and marijuana users at age 18 were at an increased risk of alcohol use disorders later at age 35. On the other hand, Lobato, Sanderman, Pizarro, and Hagedoorn (2016) reported no significant association between age and marijuana use among adolescents in Chile. Academic performance: Reports from the Canadian Youth Smoking Survey showed an inverse relationship between the likelihood of drug use and academic performance. The chances that average or below-average students had tried marijuana were 1.57 (95% CI 1.27-1.94) and 2.73 University of Ghana http://ugspace.ug.edu.gh 20 (95% CI 1.99-3.76) times higher compared to above-average students, respectively (Leatherdale et al., 2008). Likewise, users of marijuana had poorer grades, lower participation in class, had more punishments, higher rates of absenteeism and were more likely to cheat at examinations than non- users (Finn, 2012). On the other hand, another study reported that having grades of at most C+ was associated with a lower risk of alcohol use disorder than a grade of B- or higher. Truant students also had an increased risk of alcohol use disorder (Schulenberg et al., 2015). 2.5.1.2 Household Characteristics Socio-economic status: The association between socio-economic status (SES) and adolescent substance use was studied by Humensky (2010) in a longitudinal study. Parents’ highest educational level and income were used as proxies to determine adolescent socioeconomic status. Both educational level and income were significantly positively related to adolescent substance use, although the effect of income on the outcome was little. Having a college-educated parent increased the odds of binge drinking, marijuana use and cocaine use by 1.458 (95% CI, 1.19- 1.788), 1.26 (95% CI, 1.088-1.54) and 1.614 (95% CI, 1.088-2.395), respectively as compared to having a parent whose highest education level was at high school. No significant associations were observed between the use of methamphetamines and other substances and parental educational level. Also, an increase in the annual income by $1000 increased the odds of binge drinking by 1.003 (95% CI, 1.001-11.004), marijuana use by 1.002 (95% CI, 1.000-1.003), after controlling for other variables and cocaine use by 1.002 (95% CI, 1.000-1.004) in the unadjusted model. Atilola et al., (2013) also reported similar results with respect to the relationship between the educational level of parents and adolescent substance use, although findings were not statistically significant. A Swedish national cohort study reported conflicting findings. The authors used the parental level of education and position at the workplace as proxies for child SES. The likelihood University of Ghana http://ugspace.ug.edu.gh 21 of alcohol-related problems increased with decreasing SES. Children in the lowest SES group were more likely to have alcohol-related disorders later in adulthood in both crude (HR 2.37 95% CI, 2.21 – 2.55) and adjusted estimates; adjusting for demographic and parental psychosocial disorders (HR 1.87 95%CI, 1.73 – 2.01) compared to children in the highest SES group (Gauffin et al., 2013). Similarly, having a parent with not more than a high school degree in another study was associated with a higher risk of alcohol use disorder or non-disordered drinking (Schulenberg et al., 2015). Household Size: Akanni and Adayonfo (2016) studied the characteristics of adolescents that use gateway substances. The findings indicated that polygamous family background was significantly associated with tobacco use. Olufolahan and Adeyemi (2016) determined the prevalence and correlates of alcohol use among a sample of Nigerian semirural community dwellers in Nigeria. Alcohol use was more prevalent among the families with many members. The results also indicated that the determinants of any alcohol use include the family size and use. 2.5.1.3 Social and Environmental Characteristics Parental Control: A high level of parental psychological control undermines adolescent efficacy and autonomy efforts which leads to unhealthy self-concept and adjustment (Costa et al. 2019). It makes adolescents vulnerable to the development of risk behaviors including using tobacco, alcohol, and other substances. Additionally, a research by Romm and Metzger (2018) on Influence of Family Factors on Substance Use in Early Adolescents, reported a positive relationship between parental psychological control and substance use among adolescents suffering from unhealthy psychological conditions. University of Ghana http://ugspace.ug.edu.gh 22 2.5.1.4 Physiological disorders and mental disorders A study was conducted to explore the role physical and mental problems play in using or abusing drugs. University students between 18 to 35 years in Iran were studied to explore the relationship between sedative use and physical complaints, alexithymia, perceived stress and anxiety. All the factors were positively correlated with sedative use (Gilan, Zakiei, Reshadat, Komasi, & Ghasemi, 2015). The use of sedatives in this context was regarded as abuse according to the International Treaties of Drug Control, where consumption of sedatives is equivalent to its abuse irrespective of amount and frequency of use. Forray, Gotman, Kershaw, & Yonkers (2014) attempted to determine the effect of depression on smoking behavior among pregnant women and found no significant difference in the smoking behavior among women with or without depression. Furthermore, among 156 Hispanic adolescents admitted to drug treatment facilities, adolescents who had conduct disorder had twice the likelihood of heavy illicit drug use than those without conduct disorder (Gattamorta, Varela, Mccabe, Mena, & Santisteban, 2016). A cross-sectional study among 201 participants which investigated the personality traits of substance abusers showed that alcohol abuse was related to schizophrenia, hysteria, hypomania, psychopathic deviation and paranoia, as shown by chi-square and fisher’s tests. Also, the use of heroin was significantly related to schizophrenia, depression and psychopathic deviation. Depression was the most common trait among the participants (Alaghemandan, Darab, Khorasani, Maniyan, & Barati, 2015). 2.5.2 Micro-environmental factors It is well documented that a child’s physical and mental growth and development is shaped to a large extent by their environment. Parents or guardians act or pose as models, whether knowingly or unknowingly, to their children, and many learned or acquired practices or behaviors are copied University of Ghana http://ugspace.ug.edu.gh 23 from them (Maccoby, 1992). It is not surprising to come across several studies showing the effect of parental or familial substance use or abuse on their children. Other factors that constitute familial associations with drug abuse include socio-economic status, parenting behavior, chaotic home environment and abuse (whether physical, sexual or emotional). 2.5.2.1 Peer and/or parental substance abuse Adolescents are also greatly influenced by their peers, as they seek social acceptance and belonging (Bauman & Ennett, 1996; Maxwell, 2002). A cross-sectional study conducted in Ibadan, Nigeria, reported strong relationships between parental substance use and adolescent substance use. Adolescents whose mothers were substance users had a 2 fold increase in the odds of substance use compared to those whose mothers were non-users (AOR 2.00 95%CI 1.81-4.77), whilst paternal substance use increased the odds of adolescent substance use by 3 times (AOR 3.38 95% CI 2.00-4.47) (Atilola et al., 2013). Another study also reported similar findings: substance use among family members or close peers increased adolescents' likelihood of marijuana use by 5.19 (95% CI 3.221-8.350) and 7.70 (95% CI 5.007-11.836), respectively. Adolescents who were non-dependent substance users were almost thrice as likely (AOR 2.67 95%CI 1.21-5.907) to become dependent users if they had family members who were also substance users compared to adolescents who were non-users (Lobato et al., 2016). 2.5.2.2 Parenting behavior Badr, Taha, & Dee (2014) studied the association between parental attachment and adolescent drug use among Middle Eastern adolescents. Parent-adolescent attachment had a significant negative correlation with alcohol and substance use; adolescents with weak attachments to their University of Ghana http://ugspace.ug.edu.gh 24 parents had odds as high as 2.5 compared to those with strong attachments to their parents. On the other hand another study among Hispanic adolescents found that maternal attachment was negatively correlated with heavy illicit drug use; those with high levels of maternal attachment were twice as likely to be heavy illicit drug use compared to those who reported lower levels of maternal attachment (Gattamorta et al., 2016). 2.5.2.3 Trauma People who have undergone some form of trauma or abuse in their childhood may be at risk of substance abuse later in their adulthood. According to Cusack, Herring, & Steadman (2013) substance abusers who had ever been sexually abused had a significantly higher score on the PTSD Checklist (PCL), indicating that they had more severe symptoms of PTSD which acted as a mediator in alcohol intoxication and heavy drug use later in life. The odds of PTSD among those who had been victims of sexual assault was between 11 to 12 times higher than individuals without lifetime sexual assault. Consequently, the odds of alcohol intoxication and heavy drug use were 1.42 (95% CI, 1.18 – 1.70) and 1.43 (95% CI 1.20 – 1.71) times increased respectively. Similar, findings were also reported by Lopez-patton et al. (2016), where childhood trauma (physical, emotional and sexual) and depression were reported in higher frequencies among methamphetamine users relative to non-users. Use of methamphetamine was also associated with more severe forms of depression however contrary to findings by Cusack, Herring, & Steadman (2013) childhood trauma had no significant association with depression (Lopez-patton et al., 2016). 2.5.3 Macro-environmental factors Community factors that are known to influence drug use or abuse include natural disasters, availability of drugs or the use of drugs being socially acceptable, acculturation and crime rate. University of Ghana http://ugspace.ug.edu.gh 25 2.5.3.1 Exposure to drugs Out of a cohort of 1,037 adolescents studied in New Zealand who had early exposure to drugs were at an increased risk of becoming substance dependent, herpes infection, early pregnancy, criminal convictions and dropping out of school. The effect sizes for the mentioned outcomes after propensity score matching were between 2 and 3. In the same study the odds of early substance exposure were twice that of adolescents with conduct problems compared to those without conduct problems. The effects of early exposure to drugs were not very different among adolescents irrespective of history of conduct problems (Odgers et al., 2008). 2.5.3.2 Religion and Religiosity Some reports have cited religiosity as a protective factor against drug use and abuse. A score of self –reported religiosity below average among adolescents in Nigeria was associated with a 3- fold increase in the likelihood of substance use (Atilola et al., 2013). In a cross-sectional study among emerging adults (mostly in tertiary institutions) in New York City, agnostics and people who identified as “other” religion had increased in the odds of recent marijuana use compared to Christians respectively. This association was however no more significant when adjusted for attendance and self-ascribed importance of religion. Even though attendance was a significant protective factor, exposure to drugs attenuated its significance and effect in the adjusted model. This trend was observed in all models that used recent use of marijuana, cocaine, ecstasy or non- medical use of amphetamines each as outcomes. Exposure to drugs was an important and consistent predictor of substance use. The authors however, mentioned that the sequence of occurrence of exposure to users of the drugs and religiosity was not known (Palamar et al., 2014). Hodge et al. (2011) reported an increased chance of alcohol use among young people who identified with a religion compared to those who did not identify with any religion. The odds of University of Ghana http://ugspace.ug.edu.gh 26 substance use (alcohol, marijuana and inhalants) decreased as attendance at religious events increased. Lifetime use of illicit drugs also decreased with increasing attendance and self-ascribed importance attached to religion. The authors pointed out that the study was conducted among youths of Mexican heritage, where majority of them are affiliated with Catholicism which permits the use of alcohol and cigarettes among Latino religious networks. This observation could explain why religiosity in this study was positively correlated with alcohol and tobacco use but negatively correlated with the use of illicit drugs. Another study also found having an affiliation in the Catholic Church to be inversely related to recent cigarette or marijuana use, yet religious involvement had no significant effect on drug use (Parsai et al., 2010). 2.5.3.3 Acculturation A study was conducted to measure how culture and religion interact to influence substance use among Middle Eastern adolescents living in Beirut, Lebanon and Los Angeles, California. According to the results, the odds of alcohol use was higher among Christians and Muslims living in Los Angeles (2.1 95% CI, 1.3 – 3.1 and 2.9 95% CI, 1.7 – 4.5 respectively) compared to adolescents living in Beirut. However, the odds of substance use were only increased among Christians living in Los Angeles as compared to those living in Beirut (OR 2.1, 95% CI 1.3 – 3.1). This suggests that acculturation may be a stronger predictor of substance abuse than religion especially among Christians (Badr et al., 2014). Gattamorta and colleagues (2016) also found results that said otherwise. Acculturation was rather inversely associated with heavy illicit drug use; there was a 3% reduced odds of heavy illicit drug use among adolescents with higher levels of acculturation. University of Ghana http://ugspace.ug.edu.gh 27 2.5.3.4 Social networks and residence In a cross-sectional study, where gay men were recruited at two separate gay lifestyle-themes events in New York City and studied to assess how gay neighborhoods and gay-centric networks influence drug use. Gay men who lived in gay enclaves or neighborhoods had an increased odds of methamphetamine or ecstasy use (OR 4.32 95%CI, 1.37 – 13.64 and 2.41 95%CI, 1.06 – 5.45 respectively) compared to gay men who lived in other neighborhoods. Similarly, the odds of using methamphetamine were 6 times higher among gay men with gay-centric networks compared to those with a more diverse network. The associations between cocaine and marijuana use and neighborhood of residence and type of networking were not statistically significant (Carpiano, Kelly, Easterbrook, & Parsons, 2011). 2.6 Effects of drug abuse on the user As mentioned earlier in this review, substance use/abuse is not without accompanying health risks. The effect of these substances in themselves poses health consequences on one hand and may also make users engage in high-risk behaviors that increase their chances of acquiring infections such as HCV or HIV on another hand. 2.6.1 Mental Health Co-occurring HIV infection and SUDs among women in recovery increased the odds of psychological distress by almost 3 times and sleep problems increased in HIV symptoms. Opioid use was rather associated with reduced pain among the women. Alcohol, cannabis, sedatives and other substances had no significant associations with the health effects (McCabe, Feaster, & Mitrani, 2014). Supporting evidence from a ten-year perspective study in Norway, established a dose-response relationship between drug use and mental distress. The number of drugs used was also found to increase with severity of mental distress (Burdzovic, Lauritzen, & Nordfjærn, 2015). University of Ghana http://ugspace.ug.edu.gh 28 Similar trends were reported for post-traumatic stress disorder (PTSD) and psychosis in other studies (Saunders, Lambert-harris, Mcgovern, Meier, & Xie, 2016; Smith, Thirthalli, Abdallah, Murray, & Cottler, 2010). Furthermore, the use of methamphetamine/amphetamine or ecstasy (3, 4 – methylenedioxy- methamphetamine) were shown to increase the risk of depressive symptoms in a longitudinal cohort of secondary school students in deprived areas of Quebec. Adjusted estimates showed that methamphetamine /amphetamine, ecstasy and combined users were 1.6, 1.7 and 1.9 times more likely to have depressive symptoms the following year respectively as compared to non-users (Brière, Fallu, Janosz, & Pagani, 2012). Another study concurring with these findings reported higher levels of anxiety, depressive symptoms and even suicidal tendencies among inhalant dependent and inhalant abusing youth (Perron & Howard, 2009). A cross-sectional study in Nepal to measure psychosocial problems among people with substance use disorders who were receiving treatment for SUDs found frequency of substance use per day and age of onset of substance use (before 20 years) to be significantly associated with higher scores on psychosocial problems measured using the Drug Use Screening and Inventory-Revised (Poudel, Sharma, Gautam, & Poudel, 2016). The negative effects of substance use were higher in severity among early-onset (before 18 years) users than late-onset users (Poudel & Gautam, 2017). 2.6.2 Quality of life An Australian study found that PWID had a low quality of life (QOL) compared to the general population on all four domains of the World Health Organization Quality of Life (WHOQOL)- BREF, namely: physical, psychological, social relationship and environmental. Similar results were also found when comparing PWID to prisoners, and people with chronic heart disease or University of Ghana http://ugspace.ug.edu.gh 29 spinal cord injuries. Although the results were compelling, use of other substances like alcohol that may have an impact on QOL were not accounted for in the analysis (Fischer, Conrad, Clavarino, Kemp, & Najman, 2013). Furthermore, people with SUDs are known to have low self- esteem and poor social interaction skills as reported by (Ersöğütçü & Karakas, 2016). Self-esteem and social function skills were found to be positively correlated in this study. 2.6.3 Fetal and childhood development Prenatal use of cannabis specifically in the first month of pregnancy has been shown to be associated with an increased odds of anencephaly (AOR 1.7 95%CI, 1.3 – 4.9). Also using cocaine during the prenatal period was associated with an increased odds of cleft palate (AOR 2.5 95%CI, 1.1 – 5.4). The odds increased for women who used cocaine in the third month after conception to 6.8 (95%CI, 2.0 – 23) (van Gelder et al., 2009). A prospective study to assess the effects of prenatal exposure to alcohol and other substances on mental health among school-aged children. The Strength and Difficulties Questionnaire (SDQ) was used to assess mental health in exposed children. The risk of mental health problems was increased among children with prenatal exposure compared to the control group. Children who were exposed to alcohol or other substances had higher SDQ scores compared to the reference group. The highest mean difference score observed between the two groups was in the hyperactivity subscale in the questionnaire. The difference between the mental health of children exposed to alcohol only and those exposed to other substances other than alcohol was not significant (Sandtorv, Hysing, Rognlid, Nilsen, & Elgen, 2017). University of Ghana http://ugspace.ug.edu.gh 30 2.6.4 Lung health Findings from a 40-year cohort study suggest a risk of lung cancer among men who smoke marijuana. Self-reports of a lifetime use of marijuana above 50 times was associated with a hazard ratio of 2.12 (95% CI, 1.08 – 4.14) of lung cancer in the adjusted model (tobacco smoking, respiratory conditions, alcohol use and SES were controlled for). The association between lung cancer and lifetime tobacco however, did not show a dose-response relationship. There were few study participants who smoked marijuana only and so stratified analysis could not provide any persuasive results indicating a causal relationship between smoking marijuana and lung cancer (Callaghan, Allebeck, & Sidorchuk, 2013). 2.6.5 Sexual behavior Assessment of HIV sexual risk behavior in a random sample of patients receiving outpatient and residential treatment of SUDs showed that patients with alcohol dependence had three times the odds of unprotected sex when drunk than alcohol users who did not suffer from dependence and those who used cocaine had twice the odds compared to non-users (Tross et al., 2015). Current and former drug injectors had twice the odds of unprotected sex with a non-primary partner and current drug injectors also had an increased number of unprotected sex. The odds of having unprotected sex were 1.93 and 3.04 for cocaine users and problem drinkers respectively. No significant associations were observed between sexual risk behavior and marijuana or opioid use (Tross et al., 2015). Ninety four percent of 164 adolescents reported psychological or social problems as a result of alcohol intake in a study by Arias, Hawke, Arias, & Kaminer (2009). Also, the severity of symptoms associated with eating disorders were positively correlated with the number of times University of Ghana http://ugspace.ug.edu.gh 31 they got drunk weekly. The correlation coefficient however, was weak but statistically significant (r = 0.19, p = 0.011). Among homeless adults in Los Angeles, poly drug use though intravenous route were 27.1 times likely to have HCV infection, mono-drug injector had an odds ratio of 12.5 non-injection drug users had an odds ratio of 2.9 of HCV infection compared to non-users. The rate of HCV between non-injection drug users and non-users were not different, confirming the documented evidence that PWID are at an increased risk of HCV infection (Gelberg et al., 2012). 2.7 Effects of drug abuse on the family Not only does substance use and abuse impact negatively on users, their families or on the people they live with may also be affected. Familial relationships are sometimes marred as a result of comorbid mental problems and substance use and the health of family members in question are sometimes affected. Chermack et al., (2008) and Epstein-Ngo et al., (2014) examined the effects of distal (parental alcohol problems, childhood conduct disorders and youth aggression) and proximal (current drug and alcohol use and psychological disorders) factors among substance abusers in treatment programs on the frequency of partner and non-partner aggression. Proximal and distal factors were positively correlated with aggression and injury outcomes (Chermack et al., 2008). The results showed that some proximal and distal factors took direct or indirect paths to aggression. Youth aggression was directly associated with higher levels of past-year non-partner aggression (OR=1.54, p < .001) and at the same time indirectly associated with non-partner aggression through psychological distress. Alcohol use was also directly linked to non-partner aggression, whereas cocaine use and marijuana use were directly related to Partner Aggression (Epstein-Ngo et al., 2014). University of Ghana http://ugspace.ug.edu.gh 32 Mothers in substance abuse treatment programmes who had comorbid mental disorders like anxiety and depression were more likely to have their children expressing internalizing (OR 2.0 95%CI, 1.0-4.0) and externalizing (OR 3.4 95%CI, 1.5-7.6) behaviors compared to mothers in the program who were without comorbid mental disorders (Hser et al., 2015). Comorbid PTSD and substance use among fathers were also positively associated with hostility, aggression and neglectful parenting behavior towards their children (Stover, Hall, McMahon, & Easton, 2012). In Finland a study was carried out to measure the relationship between co-occurring substance abuse and maternal psychiatric problems and the psychological, behavioral, emotional and mental health of in their children between the ages of zero to twelve years. Using children whose mothers had neither substance abuse disorders nor psychiatric disorders as reference, the odds of psychological disorders was 1.33 (95% CI, 1.04 – 1.69) among children whose mothers had SUDs, 1.56 (95% CI, 1.33 – 1.84) among children whose mothers had psychiatric disorders and 1.48 (95% CI, 1.16 – 1.89) among children whose mothers had both SUDs and psychiatric disorders. Similarly, for behavioural and emotional disorders, children with substance abusing mothers had a two-fold risk (95% CI, 1.73 – 2.63) of the mentioned disorders compared to children whose mothers had neither disorder. The odds of behavioural and emotional disorders were 1.92 (95% CI, 1.65 – 2.24) and 2.62 (95% CI, 2.13 – 3.24) for children of mothers who had psychiatric disorders and both SUDs and psychiatric disorders respectively. The magnitude of the associations was slightly increased and remained significant for mood disorders and neurotic, stress-related and somatoform disorders among the children. These results show that children of substance abusing mother’s run a risk of mental health problems and subsequent substance abuse in adolescence and adulthood (Ranta & Raitasalo, 2015). Reports from the Quebec longitudinal study of child development showed a positive and significant association University of Ghana http://ugspace.ug.edu.gh 33 between long-term exposure to nicotine in the household among infants and physical aggression and anti-social behavior in late childhood. Children who had transient exposure to nicotine were 2.04 (95% CI, 1.58 – 2.64) and 1.76 (95% CI, 1.30 – 2.39) times more likely to have physical aggression and anti-social behavior respectively, compared to children with no nicotine exposure. Interestingly, children with continuous exposure nicotine exposure rather had an odd of 1.40 (95% CI, 1.17 – 1.68) for physical aggression and 1.34 (95% CI, 1.11 – 1.70) for anti-social behavior compared to children with no exposure. The authors however mentioned that the model for these estimates suffered from omitted variables bias (Pagani & Fitzpatrick, 2013). 2.8 Economic Cost of SUDs Rehabilitation There are no studies that comprehensively researched on economic cost of rehabilitation, experiences of youths in substance use rehabilitation as well as assessed quality standard of rehabilitation. A systematic review study by Addo et al, (2018) on Economic Burden of Caregiving for Persons with Severe Mental Illness in Sub-Saharan Africa, reported that there is paucity of studies on the burden of severe mental illness on caregivers in sub-Saharan Africa. Allers et al, (2015) also carried out a systematic review study on Economic Impact of Epilepsy in Sydney, Australia compared different items of expenditures and reported that drugs and hospital services were the major sources of direct costs of treatment. 2.9 Experiences of Youth with SUDs in Drug Rehabilitation Centres The experiences of youth with SUDs at the drug rehabilitation centres and their views aided in identifying the drivers of SUDs. The experiences comprised drivers of SUDs such as peer influence, loss of loved ones, curiosity, broken home, and pain and anxiety. Youths are mostly influenced by peers to participate in substance use (Gudonis-Miller et al., 2012). University of Ghana http://ugspace.ug.edu.gh 34 Drug rehabilitation experiences improve social life and family neglect (Pettersen et al., 2018). Drug rehabilitation impacts positively on self-care and developing a concern for others (Kaskutas et al., 2014). Prangley et al. (2018) noted five themes for successful recovery of SUDs, namely “improved understanding of substance uses and SUD status, reduced substance use, improved physical and psychological health, relationship success and employment success”. 2.10 Treatnet Quality Standards The Treatnet Quality Standards for Drug Dependence Treatment and Care Services was developed based on UNODC/WHO principles to help reduce the consequences of drug abuse on health, crime rates and other negative effects on individuals, families and communities globally. Its implementation is based on two core values, namely: human rights and good practice. Human rights: The Universal Declaration of Human Rights are to be applied in all aspects of the treatment procedure. The client/patient’s human rights are expected to be respected and upheld through ensuring anonymity and confidentiality, informed consent, testing HIV voluntarily, avoiding using physical or psychological coercion, contact with family members and ensuring transparent procedures for complaints. Good practice: although not compulsory, centers are encouraged to adopt this core value to promote improvement of treatment services. This comprises of five key components including prioritizing client needs, promoting multidisciplinary teamwork, ensuring written policies and standard operating procedures that stem from evidence-based medicine, good data management practices and monitoring and evaluation (UNODC, 2012). University of Ghana http://ugspace.ug.edu.gh 35 There are nine main domains of the TREATNET Quality Standards on which the questionnaire for assessing quality of treatment services is based. A summary of the nine domains is given below: 1) Availability and accessibility of drug dependence treatment: where voluntary substance dependence services are easily accessible and available, with all limitations removed. This domain also includes making services open to all without discrimination with respect to race, gender, religion, caste or any other socio-demographic characteristic of the clients. 2) Screening, assessment, diagnosis and treatment planning: providing timely and tailor- made services to clients using standard tools in clinical assessment and diagnosis. 3) Evidence-based drug dependence treatment: using the best evidence available in psychosocial and pharmacological treatment that is socio-culturally relevant to the setting with the full involvement of a multi-disciplinary team. 4) Human rights and the dignity of the patient/client: ensuring the protection of the human rights of the client and maintaining confidentiality and client’s privacy. Also, the client should not be discriminated against on any grounds whatsoever. 5) Targeting special subgroups and conditions: giving special attention to underserved populations and marginalized groups such as adolescents, women, sex workers and pregnant women. 6) Drug dependence treatment as an alternative to prison and in prison settings: addressing drug dependence as one that needs medical attention instead of incarceration or providing drug treatment services in prisons. 7) Community-based treatment: involving stakeholders in decision making concerning planning and delivery of treatment services. University of Ghana http://ugspace.ug.edu.gh 36 8) Clinical governance: application of effective policies to enable the service organization achieve its goals. Good clinical governance can be ensured by putting in place service policy respective service protocols, treatment protocols, qualified staff, supervision, monitoring systems, communication structures, financial and human resources. 9) Policy development, strategic planning and coordination of sources: ensuring a continuum of care, capacity building for staff, coordination and balance of general and specialized treatment needs (UNODC, 2012). 2.10.1 Quality of drug treatment services Brannigan, Schackman, Falco, & Millman (2004) used a scale developed by 22 experts (researchers, federal policy makers and health practitioners) which consisted of nine key elements on which the quality of drug treatment programmes for adolescents were assessed. The key elements include: assessment and treatment matching, comprehensive integrated treatment approach, family involvement in treatment, developmentally appropriate programs, engaging and retaining teens in treatment, qualified staff, gender and cultural competence, continuing care and treatment outcomes. The reliability of the scale gave a score of 0.79 (Cronbach’s alpha). Most of the programs performed poorly on the nine key elements. No program was able to attain a score of at most 4 out of a total score of 5 on each element. The mean scores were mostly between 2 and 3 for almost all the nine elements. Also, gender and cultural competence, engaging and retaining teens in treatment and assessment and treatment matching were the elements that had the poorest performance scores. The second study considered in this review examined the use of evidence-based treatment in substance abuse treatment programmes that serve American-Indians or Alaskan Natives. The use of Cognitive Behavioral Therapy, Motivational Interviewing and Relapse Prevention Therapy University of Ghana http://ugspace.ug.edu.gh 37 were among the psychosocial evidence-based treatment that were commonly used. With regard to use of culturally appropriate interventions, only Relapse Prevention Therapy and Motivational Interviewing fulfilled the criteria (Novins, Croy, Moore, & Rieckmann, 2016). In a study published by Samhsa (2015) on Screening and Assessment of Co-occurring Disorders (CODs) in the Justice System, a monograph was used to examine a wide range of evidence-based practices for screening and assessment of people in the justice system with co-occurring mental and substance use disorders. The monograph reviews a range of selected instruments for screening, assessment, and diagnosis of SUDs and CODs in justice settings and provides a critical analysis of advantages, concerns, and practical implementation issues (for instance, cost, availability, training needs) for each instrument. A number of the evidence-based instruments described in this monograph are available in the public domain. The use of evidence-based approaches for screening and assessment is likely to result in more accurate matching of offenders to treatment services and more effective treatment and supervision outcomes (Shaffer, 2011). 2.11 Summary of Systematic Review 2.11.1 Factors associated with substance abuse Being male was associated with a relatively higher risk of substance use (Leatherdale, Hammond, & Ahmed, 2008; Gauffin, Hemmingsson, & Hjern, 2013; Hodge, Marsiglia, & Nieri, 2011) although not all studies reported significant results (Parsai, Marsiglia, & Kulis, 2010) . Older teens were also found to be more likely to abuse substances compared to younger teens (Atilola et al, 2013; Schulenberg et al, 2015; Leatherdale et al, 2008). Substance abuse was negatively correlated with academic performance as well (Schulenberg et al, 2015). With respect to socio-demographic University of Ghana http://ugspace.ug.edu.gh 38 status, reports failed to agree with one direction of correlation. Some studies reported a positive correlation between likelihood of substance abuse and SES (Humensky, 2010), whiles other studies reported a negative correlation (Gauffin et al, 2013; Schulenberg et al, 2015). Furthermore, pre