University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES HEALTH SEEKING BEHAVIOURS AMONG DRUG USERS IN THE SUNYANI MUNICIPALITY BY ABDUL CADRI (10700993) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Abdul Cadri, declare that Health Seeking Behaviours among Drug Users in the Sunyani Municipality is my own original work done under supervision as a student of School of Public Health, University of Ghana and has never been submitted in part or whole for the award of a degree in any University or higher Institution of learning. All references made to other people's work have been duly acknowledged as a means of complete referencing. …………………………….. …………………………… ABDUL CADRI DATE Student …………………………….. ……………………………. Prof. COLLINS AHORLU DATE Academic Supervisor ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this research report to my beloved family; Mr. and Mrs Kadre for their support and encouragement. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am forever grateful to Allah for how far He has brought me and the wisdom He bestowed on me that enabled me carry out this study. I am highly grateful to my academic supervisor Dr. Collins Ahorlu for his guidance, commitment and support which helped me to complete this work successfully. I am also grateful to the various authorities and gatekeepers who gave me the approval and assisted me in collecting my data. Especially Mrs. Agyeiwaa Patricia. I am also thankful to all the participants who shared their honest experiences with me. This study would not have become a reality without them. I am also thankful to all my academic lecturers as well as my colleagues for their tireless support in seeing the completion of this study. I acknowledge all those who helped me in diverse ways to make this study a success. A big thank you goes to my parents and siblings who have shown me love, supported me and prayed for me throughout my journey. Finally, I wish to show my appreciation to my close friends Nagumsi Abdul Aziz Bonyo and Chizoa Olivia Madiebo Geoffrey for their help and support offered to me throughout this period. To all and many others not mentioned here, I say a big thank you and may God bless you. iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Drug use is a global public health issue and transcends cultural boundaries. Substance use and their accompanying disorders have consequences for people's mental, physical and environmental health. Drug addiction is a contributing factor to poor dental health among drug addicts. There is documented disability and comorbidity associated with drug use, nevertheless, majority of these people have never been treated and others don’t continue treatment when they start. This study therefore aims to explore the health seeking behaviours of drug users in the Sunyani Municipality Method: A descriptive study design was used employing a qualitative research approach, specifically, phenomenological study. In-depth interviews were conducted for a total of 23 participants including two Key Informants. The data collected was transcribed, coded and analyzed for the generation of themes with the aid of qualitative data analysis software “Nvivo version 12 pro”. Results: The common drugs being used in the municipality are cocaine, heroin, marijuana and tramadol. The drug users face diverse health challenges such as addiction, malaria, lungs and breathing complications, cardiovascular complications, skin complications, among others. They experience poor perceived quality of life and a low health status. The reported seeking health care from multiple sources and drug use in the Municipality was influenced by specific social and economic factors. Conclusion: Multiple sources of healthcare were used by drug users. Cost, lack of knowledge about condition and fear of arrest also served as barriers to proper healthcare. Education is needed among the drug users to improve their health seeking behaviours and access to formal healthcare. Keywords: Drug, Drug user, Health, Behaviour, Needs v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ....................................................................................................................... ii DEDICATION ......................................................................................................................... iii ACKNOWLEDGEMENT ........................................................................................................ iv ABSTRACT ............................................................................................................................... v LIST OF TABLES ..................................................................................................................... x LIST OF FIGURES .................................................................................................................. xi LIST OF APPENDICES .......................................................................................................... xii LIST OF ABBREVIATION .................................................................................................. xiii CHAPTER 1 .............................................................................................................................. 1 1.0 INTRODUCTION .......................................................................................................... 1 1.1 Background ...................................................................................................................... 1 1.2 Problem Statement ........................................................................................................... 3 1.3 Objectives of the Study .................................................................................................... 5 1.3.1 General Objective ...................................................................................................... 5 1.3.2 Research Questions.................................................................................................... 5 1.3.3 Specific objectives ..................................................................................................... 5 1.4 Justification ...................................................................................................................... 6 1.5 Theoretical background .................................................................................................... 7 1.6 Outline of the dissertation ................................................................................................ 9 CHAPTER TWO ..................................................................................................................... 10 LITERATURE REVIEW ........................................................................................................ 10 2.0 Introduction .................................................................................................................... 10 2.1 Substance abuse: aetiology and prevalence ................................................................... 10 2.2 Drugs being abused ........................................................................................................ 15 2.3 Impact of drugs on the health of users ........................................................................... 17 vi University of Ghana http://ugspace.ug.edu.gh 2.4 Health-seeking behaviour of drug users ......................................................................... 19 2.4.1 Healthcare delivery in Ghana .................................................................................. 22 2.5 Social and other factors that influence drug use ............................................................ 22 2.6 Summary of Chapter ...................................................................................................... 24 CHAPTER THREE ................................................................................................................. 25 METHODS .............................................................................................................................. 25 3.0 Introduction .................................................................................................................... 25 3.1 Philosophical worldview of the study ............................................................................ 25 3.2 Study Design .................................................................................................................. 26 3.3 Study Area ...................................................................................................................... 26 3.4 Study Population ............................................................................................................ 29 3.4.1Inclusion and Exclusion criteria ............................................................................... 29 3.5 Sample size ..................................................................................................................... 29 3.6 Sampling Method ........................................................................................................... 30 3.7 Data Collection technique .............................................................................................. 31 3.7.1 Brief description of Data Collection Tools .............................................................. 31 3.7.2 Data Processing and Data Management .................................................................. 32 3.8 Data Analysis ................................................................................................................. 32 3.9 Quality Control ............................................................................................................... 33 Training ............................................................................................................................ 33 Pre-Testing of Interview Guide ........................................................................................ 33 Supervision ....................................................................................................................... 34 Estimating Qualitative Study Trustworthiness ................................................................. 34 3.10 Ethical Considerations.................................................................................................. 35 3.11 Chapter summary ......................................................................................................... 37 CHAPTER FOUR .................................................................................................................... 38 RESULTS ................................................................................................................................ 38 vii University of Ghana http://ugspace.ug.edu.gh 4.0 Introduction .................................................................................................................... 38 4.1 Socio-demographic characteristics of participants ......................................................... 38 4.2 Drugs being abused ........................................................................................................ 40 4.3 Healthcare need of drug users ........................................................................................ 41 4.4 Health seeking behaviours ............................................................................................. 44 4.5 social and economic factors influencing drug use ......................................................... 49 4.6 Conclusion of results ...................................................................................................... 51 CHAPTER FIVE ..................................................................................................................... 53 DISCUSSION .......................................................................................................................... 53 5.0 Introduction .................................................................................................................... 53 5.1 Drugs being used ............................................................................................................ 53 5.2 healthcare needs of drug users ....................................................................................... 53 5.3 health seeking behaviours of drug users ........................................................................ 55 5.4 Social and Economic factors influencing drug use ........................................................ 58 5.5 Limitation of the study ................................................................................................... 59 CHAPTER SIX ........................................................................................................................ 60 CONCLUSION AND RECOMMENDATION ....................................................................... 60 6.0 Introduction .................................................................................................................... 60 6.1 Conclusion ...................................................................................................................... 60 6.2 Recommendations .......................................................................................................... 61 REFERENCES ........................................................................................................................ 63 APPENDICES ......................................................................................................................... 71 Appendix 1: Participant information sheet........................................................................... 71 Appendix 2: Interview Guides ............................................................................................. 77 Appendix 3: Table of themes ............................................................................................... 86 viii University of Ghana http://ugspace.ug.edu.gh ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Prevalence of smoking and smokeless tobacco (SLT) use among men and women in some selected sub-Saharan African countries .......................................................................... 14 Table 2: Street names for common drugs ................................................................................ 15 Table 3:Demographic Characteristics of Drug Users .............................................................. 39 x University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1- Conceptual framework for health seeking behaviour. .............................................. 9 Figure 2- Map of Sunyani Municipality ................................................................................. 28 xi University of Ghana http://ugspace.ug.edu.gh LIST OF APPENDICES Appendix 1: Participant information sheet .............................................................................. 71 Appendix 2: Interview Guides ................................................................................................. 77 xii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATION HBM Health Belief Model HIV Human Immune Virus ICD International Classification of Diseases IDI In-depth Interview KII Key Informant Interview LSD lysergic acid diethylamide USA United States of America xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER 1 1.0 INTRODUCTION This chapter presents an overview of the study. The chapter is made of six sections. First of all is the background information of the study. It then moves on to talk about the problem statement. The Objectives of the study as well as the research questions are then captured in the section three of the chapter. Justification is presented in section four. The fifth section then presents the theoretical background of the study and the sixth, which is the last section then presents an outline of the dissertation. 1.1 Background Drug use is a global public health issue and transcends cultural boundaries. It is not an issue that is related to a specific cultural group or race or people from a specific geographical location (Doku, Koivusilta, & Rimpelä, 2012). A substantive proportion of morbidity and mortality worldwide is accounted for by illicit substance use, and the use of substances is known to be a leading cause of preventable death (Gordon, Conley, & Gordon, 2013). Substance use and their accompanying disorders have consequences for people's mental, physical and environmental health (Gordon, Conley, & Gordon, 2013). It is prevalent in most part of the world and Ghana is not an exception. In Ireland, approximately 1 in 5 (19%) reported to have ever used illicit drug in their lifetime (O’Brien et al., 2015). Apart from alcohol, other drugs that are frequently used include cannabis, heroin, methadone, benzodiazepines, among others (O’Brien et al., 2015). Drug use has negative effects on the quality of life of an individual as well as their physical health (specifically an increase in infectious diseases) and mental health, and these have been documented by some studies (Fisher et al., 2005; Ryan and White, 1996). 1 University of Ghana http://ugspace.ug.edu.gh Some identified influences that increase the risk of drug use include experimental curiosity, influence from friends and family, lack of parental supervision, personality disorders, etc. Factors on the other hand that protects one from these drug use include effective communication in the family, effective family socialisation, and the ability to identify early warning signs of drug use (Alhyas et al., 2015). People who abuse drugs use more than one drug sometimes and have various means of administration, some of which may be detrimental to their health (Lopez & Setel, 2015). The various methods of intake include but not limited to inhalation/smoking, oral, nasally, or by intravenous, intramuscular and subcutaneous injection (Enevoldson, 2004; Lopez, & Setel (2015). Injecting drug use is widely known to be the most dangerous route of administration. People who inject drugs are at higher risk of vein damage, fatal and non-fatal overdoses, transmission of infectious diseases, among others (Havinga, Van der Velden, De Gee, & Van der Poel, 2014). Evidence of drug use at the country level in most parts of Africa and the influence of social, economic and other factors on drug use is scanty. This is often attributed to the limited research capacity, data scarcity and lack of or limited funding (John, Mamudu, & Liber, 2012). Illicit drug use is a serious public health issue with a tremendous economic impact, which is usually accompanied by high comorbidity between drug use disorders, medical and mental disorders as well as a host of social problems (Krupski et al., 2016). It has been said that drug addiction is associated with poor dental health among drug addicts and the factors which have been noted to contribute to such poor dental health include dry mouth and sweet food preference induced by opiates, cannabinoids, and stimulant together with poor oral hygiene (Reece, 2007). Drug addiction is also associated with a number of 2 University of Ghana http://ugspace.ug.edu.gh disorders which are usually age-related degenerative changes, including osteoporosis, neuropsychiatric co-morbidity, opiate neurogenesis suppression, dilutional anaemia, reduced sperm counts, accelerated hair graining and coronary calcification (Reece, 2007). There is documented disability and comorbidity associated with drug use, nevertheless, majority of these people have never been treated and others don’t continue treatment when they start (Krupski et al., 2016). Several factors influence the help-seeking behaviour for health problems among drug users, some of which include one’s desire to solve their own problem, perceived need, health literacy and financial capability (Laudet, Becker, & White, 2009). Most at times, for people to seek healthcare, they need to consider the symptoms of the ailment as a threat to their health and have the required resources at their disposal (Danso-appiah et al., 2010). Health seeking behaviour goes beyond just the cause of the disease and treating the disease. It is also influenced by the perceived severity and duration, cultural practices, socio-economic factors, perceived health care quality, medical availability and cost, distance to hospital and charged user fees (Danso-appiah et al., 2010). 1.2 Problem Statement Prevalence of drug use has been reported to be high recently and it has been argued in the past decades that patients who present dual diagnosis often have higher morbidity, poor prognoses and difficult clinical treatment outcomes (Corradi-Webster & Gherardi-Donato, 2016). In the United States of America (USA), the Substance Abuse and Mental health data of 2016 showed that about 130,610 people above 12 years used illicit drug in 2015 as compared to 130,628 in 2016, a further 117,865 used marijuana in 2015 as compared to 118,524 in 2016. A reported 38, 744 used cocaine in 2015 as compared to 38,880 in 2016 (Abuse, 2016). This implies that drug use is on the rise in the USA and the case in Ghana may not be different. 3 University of Ghana http://ugspace.ug.edu.gh Illicit drug use has an enormous economic impact and it is usually accompanied by high comorbidity between drug use disorders and both physical and mental health disorders, and most importantly, drug use is accompanied by couple of social problems such as homelessness, criminal justice involvement, unemployment and financial constraints, in the extreme case leading to poverty (Krupski et al., 2016). The physical and mental health needs of drug users have been documented worldwide (Reece, 2007; Konstantopoulos et al., 2015; Krupski et al., 2016). The presence or absence of familial and social support has also been identified to have an influence on the severity of healthcare needs of drug users, as those with familial and social support may have some or all of their healthcare needs met whereas those with family rejection and no social support may have their healthcare needs unmet (Benissa et al., 2015). Drug abuse may lead to medical consequences and several health outcomes such as unintended injuries, motor accidents, violence injuries as a result of impulsivity and aggression, Human Immune Virus (HIV), Hepatitis C, and other infectious disease because of high risk behaviours associated with it (Konstantopoulos et al., 2015). Several substances or drugs (alcohol, cocaine, crack, etc.) are being abused and they have their accompanying side effects, health and social problems (Enevoldson, 2004). The ECOWAS drug news on drug abuse menace in West Africa estimated that 1.25 million Ghanaians are thought to be having problem with drug use, mostly marijuana, while others include cocaine, heroin, methamphetamines, and other synthetic opioids such as tramadol, codeine, among others (Agbemava, 2019). Annual report from the Sunyani Regional Hospital’s mental health unit indicates that drug use is on the rise in the Sunyani Municipality as well as incidence of drug use related disorders. The report further showed that of the 2,284 patients who accessed the facility for the year, about 596(26%) were alcohol and drug abuse related cases. In the same year, out of the 1,047 new cases seen, 413 were substance abuse 4 University of Ghana http://ugspace.ug.edu.gh related disorders, with 138 having been either re-admitted or treated on at least one other occasion for the same diagnosis (Appiah, 2014). This statistics showed a 12% increase in substance abuse and relapse cases as compared to that of the preceding year (Appiah, 2014). Despite the tremendous documented effects of illicit drug use on the individual, family and nation as a whole, many drug users do not access healthcare services (Krupski et al., 2016). This study therefore sought to explore the health seeking behaviours of drug users and understand reasons for those behaviours. The study also sought to identify the social and economic factors influencing their continuous illicit drug use. 1.3 Objectives of the Study 1.3.1 General Objective To assess the heath seeking behaviours among drug users in the Sunyani municipality 1.3.2 Research Questions The specific objectives of the study will be achieved by answering the following questions: 1. What drugs are being used among the drug users? 2. What are the healthcare needs of the drug users? 3. How is the health seeking behaviour of the drug users like? 4. What social and economic factors influence drug use in the Sunyani Municipality? 1.3.3 Specific objectives 1. To identify the drugs that are being used among the drug users 2. To determine the healthcare needs of drug users 3. To describe the health seeking behaviour of drug users 5 University of Ghana http://ugspace.ug.edu.gh 4. To identify the social and economic factors influencing drug use in the Sunyani Municipality 1.4 Justification Drug abuse is a serious public health issue which has tremendous effect on an individual, the family, the society and the nation as a whole. Long term and heavy use may come with a couple of disorders, both physical and mental. Quite a number of drugs are being abused in Ghana, some of which include cannabis, cocaine, heroin, benzodiazepines, among others. Recently, the abuse of tramadol has become the topic of the day (Agbemava, 2019). Also, paint and super glue are being abused by a section of the youth who are regarded as the future leaders of the country. Drug abusers engage in several risky behaviours resulting to the use of emergency services a lot (Doku, Koivusilta, & Rimpelä, 2012; Konstantopoulos et al., 2015) . They also have other healthcare needs such as oral health issues, physical health issues (e.g. malaria, anaemia, hepatitis C, etc), mental health issues (e.g. addiction, substance induced psychosis, depression, anxiety, etc), among others (Reece, 2007; Konstantopoulos et al., 2015; O’Brien et al., 2015; Krupski et al., 2016). However, majority of drug users may not access healthcare services when the need arises, while others may use traditional health services. Nevertheless, there are reasons that may inform their health seeking behaviours, which could be explained using the Health Belief Model. The Health Belief Model proposes that, such behaviours depend on the individual’s perception of the severity of the illness, susceptibility to a particular illness, benefits from taking an action and barriers to taking that action. This study sought to identify the various drugs that are being used by drug users in the community and also assessed their healthcare needs and their healthcare related behaviours. Social and economic factors influencing drug use were also be explored. Findings of this 6 University of Ghana http://ugspace.ug.edu.gh study helped to understand drug users’ reasons for their health-related behaviours and why they still use drugs. 1.5 Theoretical background This study will use the Health Belief Model (HBM), a useful tool for explaining the predicting healthcare seeking behaviour (Asampong et al., 2015) to explain the findings. According to Glanz et al. (2002), the model was developed in the 1950s and has been widely used in understanding health behaviour. The HBM is based on the understanding that a person will take a health-related action if that person: 1. feels that a negative health condition can be avoided, 2. has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition, and 3. believes that he/she can successfully take a recommended health action The model proposes that health-related behaviour is influenced by an individual’s perception of six key areas; perceived susceptibility, perceived severity, perceived benefits, barriers, cues to action and self-efficacy. Health Belief Model suggests that individuals are usually being faced with alternatives to taking actions and usually choose the one that is most likely to yield positive outcome (Asampong et al., 2015). As a result, changes in health seeking behaviour arises under these circumstances and in the case of drug users, they are likely to seek healthcare in times of ill- health when have certain perceptions about that condition. With the case of the drug users, the perceived susceptibility to a particular health problem and the perceived seriousness of that health problem will influence their health seeking behaviour. The perceived susceptibility is the situation where the drug user belief they have a 7 University of Ghana http://ugspace.ug.edu.gh chance of suffering from a particular condition and the perceived seriousness/ severity of the health problem is the situation where the user sees how serious a health problem is and consequences accompanying it. These factors are basically the individual’s perception about the health condition and will influence their health seeking behaviour. Also, certain modifying factors such as the socio-demographics and socio-economic status of the drug user, perceived threat to the disease and cues to action will also influence their health seeking behaviour. An individual’s knowledge of a condition and where to seek healthcare from and their socio-economic status as well as other factors all have an influence on their health seeking behaviour directly or indirectly. Cues to action which basically constitutes the strategies to activate readiness such as witnessing the death of a colleague of critical health condition will also have an influence on an individual’s health seeking behaviour. Moreover, the likelihood of the drug user taking an action basically constitutes the perceived benefit of the action as against the barriers to taking a particular action and the likelihood of a behavioural change. These likelihoods of action are influenced by factors mentioned above. The perceived benefits talk about the individual’s belief in what he/she stands to gain from performing a given action to reduce the risk or impact of the health problem. This will also influence the choice of care an individual seeks. The perceived barriers on the other hand basically talks about one’s belief in the tangible and psychological costs of the advised behaviour. They are the factors that the individual sees to be a hindrance to his or her healthcare seeking. 8 University of Ghana http://ugspace.ug.edu.gh The figure below gives an overview of the health seeking behaviour model Figure 1- Conceptual framework for health seeking behaviour among drug users. source: Glanz et al, 2002, p. 52 1.6 Outline of the dissertation This dissertation is made of six chapters. Chapter one presented the background of the study, the problem statement, justification, objectives and research questions underlying the study. The chapter two presents related literature on the key concepts underlying the topic under review. In chapter three, the methods that were used in the study have been presented as well. The fourth chapter presents the results of the study while the discussion of the study findings is presented in the fifth chapter. Lastly, the conclusion and recommendations of the study are presented in the sixth chapter. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter present in-depth insight into previous studies that have been conducted on drug use, the associated health problems, the healthcare needs of drug abusers, their health seeking behaviour and social and economic factors that influence illicit drug use. The chapter is made of five sections. The first section looks at substance abuse including drug use and alcohol use, its aetiology and prevalence. Section two presents literature on drugs being used whereas section three looks at the impact of drug use and health needs of drug users. Section four then describes the health seeking behaviour of drug users and section five talks about the social and other factors influencing drug use. 2.1 Substance abuse: aetiology and prevalence According to the American Psychiatric Association, substance abuse, including alcohol and drug abuse is defined as the maladaptive pattern of substance use that leads to significant clinical impairment, as manifested by one (or more) of the following in a 12-month period: • recurrent use resulting in failure to fulfil obligation, • recurrent use in situations that are physically hazardous, • associated legal problems, and • recurrent use despite the social consequences. After prolonged use of alcohol and drug, it may develop to dependence which is characterized by tolerance and withdrawal (Liu, Lien, & Fenske, 2010 ). 10 University of Ghana http://ugspace.ug.edu.gh In this work, drug use is regarded as use of any chemical that interacts with the central nervous system and changes subjective experience, behaviour or both (Campbell et al., 2009). Drug dependence is defined as a brain disease in which impaired control over drug use is the main symptom and people cannot stop using without a sort of help. Drug addiction is also defined as the inability of an individual to stop using drug even under adverse conditions (B. John & Erickson., 2013). Drug use is often regarded as a maladaptation, especially in people who have inherent genes or presence of environmental factors that predispose them to addiction (Campbell et al., 2009). People who use drug sometimes combine several drugs and use. There are several methods of intake such as smoking, inhalation, oral method, or injection (Enevoldson, 2004). Five broad categories of drugs that people usually use exist and they include stimulants, sedatives, hallucinogens, organic solvents, and drugs used to enhance athletic performance. Enevoldson, (2004) outlined cocaine/crack, amphetamine, dioxymethylamphetamine ‘‘Ecstasy’’, phenylpropanolamine, ephedrine and methylphenidate to be stimulants. He indicated that they have an impact on transmission at the catecholaminergic synapses and have effects in excess. Motor manifestation of overdose or excess intake are tremor, myoclonus and seizure while the neuropsychiatric manifestation on the other hand include irritability, violence, and psychotic state. It was further indicated that the sedatives which mainly include heroin and other opiates usually gives a sense of euphoria and there will be increased anxiety and alertness in others. When taken in excess, it leads to coma and deep respiratory depression along with hypotension and non-cardiogenic pulmonary oedema. With the hallucinogens, which was originally used as an anaesthetic agent, Enevoldson, (2004) reported that, it produces a mixture of effects, some stimulants, some depressants. Abuse is associated with hallucinations due to increased sensory perceptions, and affects several neurotransmitters including dopamine and acetylcholine. It is associated with changes 11 University of Ghana http://ugspace.ug.edu.gh in perception, decrease pain, and autonomic effects with flushing, increased blood pressure, sweating, among others when taken in high dose. Marijuana, ketamine and lysergic acid diethylamide (LSD) were stated to have hallucinogenic effects. Enevoldson, (2004) indicted in his report that the organic solvents are usually used by adolescents who want to experiment with all kinds of substances which are organic solvents- based such as toluene, hexane and benzene (light fluids, varnishes, paint thinners, etc.). These can give rise to a sense of exhilaration, associated with some light headedness and giddiness, and sometimes auditory and visual hallucinations. Further characteristics include vomiting, tinnitus and later headache. The effects are short-lived (e.g. half an hour) and often lead to repeated use to keep the buzz. Finally, with drugs improving athletic performance, it was reported that they are usually abused by sportsmen to improve performance. Body builders, athletes and other gym users, for example, use a variety of drugs for a variety of purposes, including anabolic effects, stimulants to increase alertness, reduce fatigue and prolonged endurance. Several reasons account for drug use and in a report by Mu and Schumann, (2018), it was indicated that some factors that are associated with drug use include sexual performance, improved functioning, anxiety, fatigue, coping with stressful life events, among others. According to Oser et al. (2012), stimulant which comprises cocaine (crack and powdered) amphetamine and methamphetamines are associated with increased alertness. It was further indicated that there are contradictory investigations into stimulant availability in the United States' rural areas. It was reported that while some studies report lower prevalence of the use of cocaine in rural areas, others report availability of these drugs in the rural areas and thus, prevalent use in those rural areas. They indicated that crack cocaine and powder cocaine may be available but may not be the preferred drugs in certain rural areas. Due to affordability in 12 University of Ghana http://ugspace.ug.edu.gh terms of cost, amphetamines, in particular methamphetamine, are becoming increasingly popular in rural populations. Oser et al. (2012) also reported that those who use methamphetamine spend about a quarter of the money that cocaine users spend, but methamphetamine users have a longer influence because of the long-lasting effects of methamphetamine. In addition, rural areas are a prime location for methamphetamine production and distribution due to the availability of ingredients including agricultural fertilizers, distressed economic conditions and insulation. While the production and distribution of methamphetamine may be prominent in rural areas, there are limited opportunities for treatment services for substance abuse in less densely populated areas (Oser et al., 2012) The prevalence of drug use varies across different parts of the world and some available information indicate that substance use is on the rise. In the USA, the Substance Abuse and Mental health data of 2016 showed that about 130,610 people above 12 years used illicit drug in 2015 as compared to 130,628 in 2016, a further 117,865 used marijuana in 2015 as compared to 118,524 uses in 2016. A reported 38, 744 used cocaine in 2015 as compared to 38,880 uses in 2016 (Abuse, 2016). In a study conducted by Sreeramareddy, Pradhan, and Sin (2014) on the prevalence, distribution and determinants of tobacco use in 30 Sub-Saharan African countries, it was found that the prevalence of Tobacco use in some African countries varied and a few of them are shown in the table below. 13 University of Ghana http://ugspace.ug.edu.gh Table 1: Prevalence of smoking and smokeless tobacco (SLT) use among men and women in some selected sub-Saharan African countries Country Men women Smoking (%) SLT use (%) Smoking (%) SLT use (%) Eastern Africa Kenya 18.65 2.05 0.35 1.29 Rwanda 12.91 5.80 1.01 2.73 Madagascar 28.54 24.66 1.56 19.63 Western Africa Ghana 7.55 1.33 0.17 0.20 Nigeria 9.20 3.78 0.22 0.46 Sierra Leone 37.68 1.54 6.06 4.74 Central Africa Cameroon 14.77 1.94 0.57 0.94 Congo Republic 20.68 8.67 0.99 3.22 Gabon 22.38 0.48 3.11 0.34 Southern Africa Lesotho 34.14 1.40 0.34 9.12 Namibia 21.84 1.83 5.87 2.31 Swaziland 14.40 2.81 1.13 1.03 Source: ( Sreeramareddy, Pradhan, & Sin, 2014) Similar to the study on prevalence of tobacco use in various countries in Sub-Saharan Africa including Ghana, John, Mamudu, and Liber, (2012) reported the prevalence of tobacco in Ghana to be 7% and 0.4% among men and women respectively. Another study conducted by Asante, Meyer-weitz, and Petersen, (2014) to examine the relationship between substance use 14 University of Ghana http://ugspace.ug.edu.gh and risky sexual behaviours among homeless youth in Ghana reported the prevalence of marijuana use and alcohol use among them to be 16.2% and 12% respectively. 2.2 Drugs being abused Several substances exist with their street names and are being abused across age groups in different parts of the world. Enevoldson, (2004) reported common drugs and their street names (table 2) Table 2: Street names for common drugs Drug Street name Cannabis Marijuana, Puff, Hashish, Dope, Ganja, Hemp, Weed, Cocaine Coke, Charlie, Lady, Percy, Snow, Toot Crack Base, Gravel, Pebbles, Rocks, Stones, Wash Amphetamines Speed, Base Ice, Crystal, Billy, Whiz, Dexies Methamphetamines Crystal Meths, Ice, Krank, Tina, Tweak Ecstasy E, X, XTC Brownies, Eckies, Hug drug, M & Ms, Sweeties ℽ hydroxybutyrate Liquid Ecstasy, Midnight blue, Blue nitro Heroin H, Horse, Smack, Skag Ketamine Green, K, Special K, Supa K and Vitamin K LSD Acid, Lucy, Tabs Poppers Liquid Gold, Ram, Rock hard, Thrust Magic mushrooms Shrooms, Mushies, Happies, Sillies, Liberties Source: (Enevoldson, 2004) A study conducted by Corradi-Webster and Gherardi-Donato, (2016) reported that drugs frequently used among psychiatric outpatients in Sao Paulo, Brazil were tobacco, alcohol, cocaine, cannabis, amphetamines, inhalants and hallucinogens. The drug that was frequently used was tobacco, followed by alcohol. Hallucinogens and amphetamines were among the 15 University of Ghana http://ugspace.ug.edu.gh drugs that were least used. Sikmilarly, Robbins, Wenger, Lorvick, Shiboski, and Kral, (2010) reported that substances that were frequently used among homeless injection drug users in San Francisco were heroine, speedball (heroin/cocaine), cocaine, crack cocaine, amphetamine, prescription opiates, benzodiazepines, and marijuana. Grant et al. (2011) reported in their study conducted among co-twins who served in the U.S military during the Vietnam-era that, drugs that were frequently abused among them were cannabis, stimulant/cocaine, sedatives, opiates, hallucinogens, any non-cannabis and regular alcohol use. Alcohol was the most frequently used, followed by cannabis. Opiates were the least used drugs among the respondents. Also, Oser et al. (2012) reported in their study conducted in the U.S.A that drugs used among participants included marijuana, crack, powder cocaine, pharmaceutical methamphetamine, non-pharmaceutical methamphetamine, amphetamines, heroin, non-prescription painkillers, and tranquilizers. They also indicated that marijuana was the most commonly used illegal drug by rural drug users, and that marijuana was used every other day by participants. In the past 30 days, rural drug users reported using alcohol for 11 days, using crack for 7 days, using cocaine powder for 4 days, using pain killers without prescription for 5 days and using non-pharmaceutical methamphetamines about 4 days. In addition, in their teens and early twenties, these rural drug users initiated their alcohol and other illicit drugs use. They reported using substances such as alcohol and marijuana 14.30 years and 14.62 years respectively while using crack and heroin 24.53 and 23.45 years of age. Krupski et al. (2016) in their cross-sectional study in Washington reported that the majority of participants admitted to use marijuana in the preceding 30 days (76 %), 42 % to use stimulants, 26 % to use opiates and 8 % to use intravenous drugs; 45 % admitted to use 2 or more drugs in the previous 30 days. Almost 69% reported alcohol use in the previous 30 days and 72% reported nicotine use. 16 University of Ghana http://ugspace.ug.edu.gh 2.3 Impact of drugs on the Health of users The different broad categories of drugs have various varying effects on individuals when they use them. In that regards, Enevoldson (2004) reported that stimulants have health effects such as seizures, psychotic symptoms, cardiac arrhythmias, sleep disturbances, anxiety, stroke, headache, hyperplaxia, cognitive dysfunction, cerebral atrophy, among others. With the sedatives, Enevoldson (2004) reported its health effects to be anxiety, nausea, vomiting, difficulty passing urine, flushing, dry mouth, coughing, respiratory problems, coma, cardiorespiratory arrest, among others. Hallucinogens were reported to have health effects such as depression, hallucination, raised blood pressure, tachycardia, some neurological problems, among others. With the organic solvents, health effects such as hallucinations, double vision, dysathria, nystagmus, respiratory depression, coma, ocular motor abnormalities, among others. To add to it, Gordon, Conley, and Gordon, (2013) also reported in their review of literature on medical consequences of marijuana that its use decreases the activity of the immune cells thereby increasing the risk of a wide range of infectious diseases like tuberculosis, among others. They further indicated that use of marijuana increases risk of other diseases like cancer, oral cavity diseases, pulmonary diseases, cardiovascular diseases, neurological diseases, ocular diseases, urological and renal diseases, digestive diseases and gynaecological diseases like trichomonas vaginalis, among others. Different groups have different healthcare needs. Otwombe et al.(2015) reported in their study that the commonly reported healthcare needs of adolescents were general healthcare services, counselling services, reproductive health services, addiction counselling services and gynaecological services. They further indicated that even though some of those services were at that time available to the adolescents, they perceived that those services were unavailable adequately to meet their needs. Similarly, Asampong et al. (2015) reported in 17 University of Ghana http://ugspace.ug.edu.gh their qualitative study that the health conditions respondents were exposed to include physical injuries, self-reported chest pains or symptoms of respiratory tract infections, malaria attacks, headaches, body pains, stomach discomfort and stress. One important factor which may lead to unmet healthcare needs of a group of people is usually availability or unavailability of familial and social support (Benissa et al., 2016). Drug use including alcohol has a tremendous health effects on the users and Liu, Lien, and Fenske, (2010) reported that its usage comes along with a couple of skin diseases such as spider telangiectasias, jaundice, pruritus, hyperpigmentation, skin ulceration, psoriasis, seborrheic dermatitis, porphyria cutanea tarda, urticaria and in the worst case, skin cancer. It was also reported that there are times when long term alcohol and illicit drug use leads to nutritional deficiencies. Oedema was also reported to be associated with the long-term use of alcohol and illicit drugs. In a cross-sectional study conducted by O’Brien et al. (2015) to investigate the association between drug use and physical health, anxiety and/or depression, and quality of life among homeless drug users in Ireland, it was reported that anaemia, deep vein thrombosis, gastrointestinal tract disorders, skin problem and hepatitis C were predominant in them. Drug users were five times likely to develop multimorbidity as compared to non-drug users. An association between poor self-reported perceived quality of life and current illicit drug use was found when univariate analysis was done with drug users five times likely to report poor quality of life compared to non-drug users (OR 5.18, 95% CI 1.68-16.01, p=0.04). After adjusting for the effect of certain variables, current illicit drug users were four times more likely to report poor quality of life as compared to those who never used it. Almost half of the drug users reported with oral health problems but they were significantly less likely to visit the dentist as compared to non-drug users. 18 University of Ghana http://ugspace.ug.edu.gh Robbins, Wenger, Lorvick, Shiboski, and Kral,( 2010) reported in their study which aimed at describing the prevalence and correlates of health care needs and health-seeking behaviours among Injectable drug users that, medical and oral health care needs are common among drug users. Krupski et al. (2016) in their findings indicated that individuals who used illicit drugs and sought primary care in a safety-net medical setting had multiple co-existing social, psychiatric and health problems. Drug addiction has been reported to have an association with poor dental hygiene and it is in this light that Reece (2007) in his cross-sectional study, reported that drug addicts usually have more than twice missing, rotten, traumatized and extracted teeth as compared to controls, and that, just over half of the teeth were rated " fine". Similarly, Metsch et al. (2002) showed in their study that those who use cocaine for a long period of times are likely to report the presence of dental problems regardless of the route of transmission. 2.4 Health-seeking behaviour of drug users Health-seeking behaviours varies across different groups and are influenced by quite a number of factors and particularly in mental health problems, alcohol use problems and drug use problems, literacy (knowledge and beliefs that aid in recognising, managing and preventing mental health related issues) and different ways of conceptualising the issue has a great influence on the health-seeking behaviour (Mccann, Mugavin, Renzaho, & Lubman, 2016). Danso-Appiah et al. (2010) reported in their study conducted in Ghana that the mechanisms that drive health-seeking behaviour are complex and require multidimensional approaches that combine all aspects of health access and use. They also pointed out that these behaviours are influenced by the importance of the perceived severity of the symptoms of a health problem and sometimes others who ask for health care before they seek them. It was also reported that individuals with a good socio-economic background seek health care and visit health facilities more frequently than people with a low socio-economic status and that 19 University of Ghana http://ugspace.ug.edu.gh respondents frequently report " lack of money " as a reason for not seeking care for symptoms. A study conducted by Otwombe et al.(2015) to investigate the health-seeking behaviours of adolescents in Soweto, South Africa reported that the most commonly desired health services among adolescents were general health, counselling, reproductive health and addiction counselling and the main reason for seeking medical care was flu-like symptoms while other reasons were dental, concern about HIV, injury and circumcision-related issues. Among those who had been hospitalised in the previous 6 months, the most common reason for hospitalisation was injury. Other reasons for hospitalisation were Tuberculosis/Respiratory problems, surgical procedures and pregnancy or obstetric related issues. Some of the adolescents also reported to have sought services for depression and suicidal ideations as well as related issues. Similarly, a qualitative study conducted by Asampong et al. (2015) in Ghana reported that the respondents use different sources of healthcare and use multiple sources simultaneously sometimes. They further indicated that that self-treatment, reliance on traditional medicine, use of local drug stores and use of hospitals and clinics were the main health seeking practices among the electronic waste workers. Due to the geographical convenience of the drug stores, many workers reported using the place frequently. The use of traditional medicine was also popular among them and they considered it to be cost effective. Factors that influenced their health seeking practices were reported to be accessibility, severity of health condition, perceived benefit of treatment, quality of service, ease of communication with service providers and cost of care. Another study conducted by Mohammed et al. (2015) among injection drug users in Dhaka, Bangladesh found that approximately one third (33.3%) of the participants reported local 20 University of Ghana http://ugspace.ug.edu.gh MBBS (Bachelor of Medicine and Bachelor of Surgery) Physicians or physicians registered at primary care centres followed by private medical centres (19.2 %), public health centres (10.8 %), local pharmacies (10.0 %) and paramedics, homeopathic, quacks, or traditional healers (8.3%) as a source of seeking healthcare. About 18.3% of the participants reported not seeking healthcare before. During the interview, the majority of respondents (40.0 %) said that they did not know where to go for treatment for drug addiction problems, 30% thought that treatment was too expensive, 17.5 % said that treatment was not effective and only 15 % said other causes. Nevertheless, certain factors are documented to be barriers to health-seeking. In a qualitative study conducted by Mccann, Mugavin, Renzaho, and Lubman (2016) to explore health- seeking barriers and facilitators for mental health and drug use problems, it was found that stigma, lack of mental health, alcohol and drug literacy, perceived lack of cultural competency of help sources and financial costs served as barriers to access to formal help for mental, alcohol and drug use disorders. With the stigma, it was reported that people felt shy disclosing their problem and saw seeking for help as a sign of personal weakness. With literacy being a barrier, it was reported that there was poor literacy regarding early recognition of signs and symptoms and help was sought only when the case became worse. On the basis of perceived lack of cultural competency of help sources, it was indicated that the lack of help sources that are culturaly oriented and understands participants’ culture detered them from seeking help and lastly with the financial costs, it was reported that such services are usually provided by spcialists and often regarded as expensive and many people cannot afford it. Danso-appiah et al. (2010) however, reported in their study that perceived lack of quality of service provided was not found to be an import determinant for health- seeking. 21 University of Ghana http://ugspace.ug.edu.gh Hong et al. (2008) found that the high cost of health services and the lack of health insurance led to the underutilization of health services among migrants, leading to a series of ineffective behaviours in search of health, such as unsupervised self- treatment, unregulated clinics or " just hold on" without seeking medical care. They were often seriously ill when they received formal or professional care. In their study, Iversen et al. (2011) identified three main barriers to mental health services in the United Kingdom armed forces and they included stigma, access to services and care providers ' attitudes. 2.4.1 Healthcare delivery in Ghana According to Danso-Appiah et al. (2010), the delivery of healthcare in Ghana is based on the concept of primary health care. In each district capital, at least one government hospital is located and staffed by one or more qualified medical doctors, nurses, pharmacists, laboratory technicians, auxiliary nurses and other support staff. District hospitals deal with all cases except specialized care and serious cases which are referred to the regional tertiary hospitals. There are also a number of health centres in the sub- districts, mainly without laboratory facilities, that are run by a medical assistant or a nurse. In the district and sub- district capitals, there are also private clinics and chemical stores / pharmacies. 2.5 Social and other factors that influence drug use Several factors may influence the early initiation and continuation of illicit drug use. Nevertheless, there are other factors that may serve as protective factors to initiation of drug usage and the continuity of use. A qualitative study conducted by Alhyas et al. (2015) to identify the factors that influence substance use among the youth in Abu Dhabi found that poor parent-adolescent relationship influence the initiation into drug use. This was in various forms such as poor parental 22 University of Ghana http://ugspace.ug.edu.gh monitoring, family disturbance (conflict and instability), among others. Also, peer pressure and individual factors influenced the use of substances. Factors reported under this include experimental use as a result of influence by friends, boredom, attractive look of the substance, among others. Substance accessibility was also reported to be among the risk factors as it was easily accessible and they could always get it to use with the little money they had. Protective factors on the other hand were good monitoring of children, good parent- adolescent relationship, awareness on drug associated harms, being involved with good and healthy peers, involvement of psychologists, increased social activities, activating the role of social workers in preventing drug use, among others. In a cross-sectional survey study conducted by Doku, Koivusilta, and Rimpelä, (2012), to identify the socioeconomic differences in alcohol and drug use among Ghanaian adolescents, it was reported that a lower level of material affluence scale was associated with a higher prevalence of marijuana use, other drugs and alcohol use. Experimental alcohol and marijuana use were also found in those with high material affluence. Similarly, John et al. (2012) also reported in their study on socioeconomic implication of tobacco use in Ghana that tobacco use was higher among poverty stricken regions, those with low level of education, and those with lower level of wealth. Amonoo-Lartson and Pappoe, (1992) also conducted a survey among nine secondary (high) schools in the Greater Accra Region of Ghana and reported that 31.1% of students have smoked before and that 10.3% smoke cigarettes regularly. They further indicated that significant number of those who had ever smoked (32.6%) came from high socio-economic homes as exemplified by the level of education of the father. Corradi-Webster and Gherardi-Donato, (2016) conducted a study to explore the factors that influence problematic drug use among psychiatric outpatients and found that some factors (both demographic and other factors) were associated with problematic drug use. Marital 23 University of Ghana http://ugspace.ug.edu.gh status was found to be statistically significant with problematic drug use with those who are single or not living with a steady partner using drugs frequently. Religious practice and problematic drug use were also found to be statistically significant and here, those who were no affiliated to any religion used it frequently. Involvement in social activities was also found to be statistically significant as well as dissatisfaction with the community of residence of the client. Other factors such as, experience of discrimination and dissatisfaction with financial situation was also found to be statistically significant with problematic drug use. Factors such as employment status, education, family history of drug use, experience of violence and impulsivity and problematic drug use was not statistically significant. 2.6 Summary of Chapter This chapter reviewed the existing literature on the subject matter the looked at the conceptual framework and theory used for the study. Firstly, the concept of drug use was looked at and its prevalence across different parts of the world. The researcher also looked at the classes of drugs available and the reasons why drugs are being used. Furthermore, the chapter looked at the existing literature on various drugs that are being used by various groups across different parts of the world. The healthcare needs of different groups were also looked at and the chapter also perused and examined literature on health seeking behaviours across different groups. The chapter then looked at existing literature on the factors that are influencing drug use and also talked briefly about healthcare delivery in Ghana. The next chapter presents the methods of the study. 24 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.0 Introduction The chapter three of the study presents the study methods. There are thirteen sections in this chapter. Section one presents the philosophical worldview of the study followed by section two which presents the study design. Section three then presents an overview of the study area. Section four moves on to talk about the study population, inclusion and exclusion criteria. Also, issues concerning the sample size is captured in section five. Furthermore, section six presents the sampling method and section seven talks about the data collection method. Section eight then looks at the data analysis approach of the study. In addition, section nine presents the quality control of the study. Section ten then talks about the ethical consideration of the study. Sections eleven and twelve presents the study timelines and budget respectively and finally, section thirteen presents the summary of the chapter. 3.1 Philosophical worldview of the study Research philosophy refers to the way the researcher develop knowledge, especially in relation to how data should be collected, analysed and applied (Bajpai, 2011). Different research philosophies are in existence and are linked to different research purposes, objectives and questions (Saunders, Lewis, & Thornhill, 2012). The various types of research philosophies include Post positivism, constructivism, pragmatism and transformative (Creswell, 2009). However, based on the objectives of this study, the researcher applied the constructivism/ constructivist worldview. The choice of this philosophical perspective (constructivism or social constructivism) was based on the research objectives and this philosophy being typically seen as an approach to 25 University of Ghana http://ugspace.ug.edu.gh qualitative research (Creswell, 2009). Under this philosophy, it is believed that individuals usually seek understanding of the world in which they live and work and develop subjective meanings of their experiences. Hence, making constructivism the best approach to qualitative research and for that matter this study. 3.2 Study Design A research design, known to be the back bone of a study is an important tool of the study as it provides the clue of the structure of the research and indicates how all the major parts of the research articulates to meet the research objectives (Trochim & Donnelly, 2005). A descriptive study design was used employing a qualitative research approach, specifically, phenomenological study. A qualitative study was deemed appropriate as it gave the researcher opportunity to gain a deeper understanding into health seeking behaviours of the drug users(Adongo et al., 2016). Phenomenological research, a design of enquiry from philosophy and psychology deals with describing the lived experiences of individuals about a phenomenon and it culminates in the experience of multiple individuals experiencing the same phenomenon (Creswell, 2009). It allows participants to share their perceptions, feelings and lived experiences and how these affect their viewpoint about a given situation (Adongo et al., 2016)As a result, phenomenology was used in assessing the health seeking behaviours among drug users which this study aimed to achieve. 3.3 Study Area The study was conducted in the Sunyani East Municipality. It is one of the districts in the Brong-Ahafo region and according to the 2010 population and housing census, it has a total population of 123,224 (61,610 males and 61,614 females). It has a land area of 506.7km2. It lies between latitudes 7020’N and 7005’N and longitudes 2030’W and 2010’W. It shares border with Sunyani West District, Dormaa East District, Asutifi District and Tano North District (fig.2). The municipality is composed of diverse ethnic groups but predominantly 26 University of Ghana http://ugspace.ug.edu.gh inhabited by the Akan speaking ethnic group. Other tribes such as, ewes and Ga-Dangme are the smaller population group in the municipality. Quite a number of educational facilities exist in the municipality ranging from creche to tertiary level. Six hospitals, twelve clinics, seven CHPS compound, three maternity homes and three health centres provide health services for the inhabitants of the municipality. Drug use is prevalent in the municipality with a number of patients that report to the mental health units of the Municipal Hospital and Regional Hospital to seek treatment as a result of drug/substance use mental health disorders. The main ghetto in the municipality is situated directly in the center of the town and quite a number of people visit there day in day out to have access to drugs. 27 University of Ghana http://ugspace.ug.edu.gh Map of Sunyani Municipality Figure 2- Map of Sunyani Municipality Source: GSS, GIS (2014) 28 University of Ghana http://ugspace.ug.edu.gh 3.4 Study Population According to Trochim & Donnelly(2005) , a population is a complete group of people with common specialized characteristics. The study population was both male and female drug users aged 18 to 65 who reside in the Sunyani Municipality. 3.4.1Inclusion and Exclusion criteria Inclusion Criteria All drug users who were within the preferred age limit and acknowledged using an illegal drug or a prescription medication for nonmedical reasons at least once in one month ago were included in the study. Also, those who were in the sober state and consented to be part of the study and were available at the time of data collection were included in the study. This age limit and informed consent were to ensure that participants themselves had agreed to be part of the study. Exclusion criteria All drug users who did not meet the age limit, were not in the sober state, did not consent to be part of the study and those who were seriously ill at the time of data collection were excluded from the study. Also excluded were drug users with severe cognitive impairment, or active psychosis in order for participants to provide informed consent and able to fully comprehend and participate in the interview process. 3.5 Sample size A section of a complete population can be termed as a sample(Banerjee, Cole, Duflo, & Linden, 2005). Respondents were sampled until saturation was reached, thus where no new information was achieved. It is known that in a phenomenological study, a sample size of 20 29 University of Ghana http://ugspace.ug.edu.gh is enough to reach saturation (Green & Thorogood, 2014). In this study however, 23 participants were interviewed including two key informants. 3.6 Sampling Method Eligible drug users in the Sunyani Municipality were sampled using snowball and purposive sampling technique. Snowballing was used to sample drug users in the community who have never been diagnosed of any mental and behavioural disorders due to psychoactive substance use according to the International Classification of Diseases (ICD) 10 Classification of mental and behavioural disorders and are mostly in the ghettos. Purposive sampling on the other hand was used to sample drug users who have once been diagnosed of any mental and behavioural disorders due to psychoactive substance use according to the ICD 10 Classification of mental and behavioural disorders and still use the substance. Heterogeneous sampling, a type of purposive sampling and also known as maximum variation sampling was used in selecting respondents with a history of diagnosis to help get those that exhibit a wide range of experiences and behaviours which helped us gain a greater insight into the phenomenon of interest (Green & Thorogood, 2014). Hospital records were reviewed and information on age, sex, diagnosis, marital status, education, area of residence, history of drug abuse and adherence to medication were used to inform the selection of participants into the study. Eligible participants were then contacted by the head of department at the mental health unit and informed of the study and given a chance to decide on whether to participate or not. Among those at the ghetto, contact was first made with the gatekeeper and informed about the study in order to gain entry into the ghetto. Eligible participants that were readily available and convenient were then selected and included in the study. 30 University of Ghana http://ugspace.ug.edu.gh 3.7 Data Collection technique Qualitative data collection approach was employed which gave us the opportunity to select the few and best cases for the in-depth interviews (Green & Thorogood, 2014). Approved letters were sent to the necessary authorities and frequent follow-ups were made until permission was granted to carry out the study at the selected areas and facility. The various gatekeepers at both the health facility and ghetto were then contacted for selection of participants into the study. In-depth interviews were organised for respondents at their convenient location and time, after dialoguing with them to arrive at a consensus and then followed by Key Informant Interviews which were conducted with the various gate keepers. The in-depth and key informant interviews lasted for about 10 to 25 minutes each. 3.7.1 Brief description of Data Collection Tools In-depth Interviews and key informant interviews were conducted with the use of a semi- structured interview guide. Two different guides were developed. The guides were developed in English and translated into the local language by language experts using a back-to-back strategy. This strategy ensured that a language expert proficient in English and the local language were made to translate the interview guide from English to the local language and another expert was made to translate it from the local language to English. The two conversions were then checked and where there were difference, it was discussed among the language experts with a third language expert as the mediator. This was done to ensure uniformity in data collection tools. The first interview guide was for drug users who have had a diagnosis and seek treatment from the health facilities in the Municipality. The second one was for drug users who are mostly in the ghettos and have never been diagnosed of any mental or behavioural disorder per the ICD 10 Classification of mental and behavioural disorders. Participants’ demographic 31 University of Ghana http://ugspace.ug.edu.gh information were captured and in addition to that, the in-depth interview guide also explored thematic areas such as drugs used by participants, their health needs, illness characteristics, factors influencing continuation of drug use, and their health seeking behaviour and practices. Another guide was focus on key informant's view of participants’ health needs, their health behaviours and factors influencing continuity of drug use in the municipality. More so, the barriers to health seeking were also be explored from the key Informants perspective as well as participants’ perspective. 3.7.2 Data Processing and Data Management Permission was sought from participants for the interviews to be audio-recorded. Participants were assigned unique codes instead of using their names and each interview begun by first mentioning the number on the interview guide to ensure data collected and analysed belong to the right participant. All interviews were conducted in languages that are best understood by participants. Field notes were made promptly after each interview and transformed into a data document. The field note covered the initial interviewee's reactions to the interview, and any relevant observations such as the demeanour of the respondent, body language and emotions, that were not be captured by the digital recording. Data gathered was stored on the personal computer of the principal investigator with limited access to the research team. Audio recordings were deleted immediately after they were transcribed. 3.8 Data Analysis The recorded interviews were listened to for about three times as a means of familiarisation with the data. The taped interviews were then transcribed by two independent people and compared for consistency. An inconsistency was discussed among them with a third person 32 University of Ghana http://ugspace.ug.edu.gh as a mediator. The transcripts were read all over again to gain a broader understanding of participants’ health-seeking behaviours before they are imported into NVivo 12 pro software for analysis. A thematic analysis was used employing both deductive and inductive analysis (Creswell, 2009). A codebook containing the various codes that are to be used was generated based on the objectives of the study and the subject areas explored during the interviews. Each transcript was opened in the NVivo software and line-by-line reading and coding of all the statements was done. The coding was reviewed, where some categories were developed and then merged to develop themes. Codebook developed initially was revised as coding continued. Major and sub-themes emerged and the table of themes was then exported to word processor (Microsoft word) for further interpretation of the data. Also, each node was exported back into word for easy reading and selection of the best quotes which presented in the results section of the work. 3.9 Quality Control Training To aid in an effective data collection, research assistants were recruited and given adequate training to better understand the aims and objectives of the study. They were well trained on how to conduct interviews in the local language of the participants. This helped in the process of data collection in situations where participants were unable to speak the English language. Pre-Testing of Interview Guide The data collection instrument was be pre-tested with three participants. This served as an opportunity for practice before the conduction of the main study (Yin, 2011). This helped in 33 University of Ghana http://ugspace.ug.edu.gh refining different aspects of the study including fieldwork procedures and data collection tool. Additional probe questions were added to the patients' In-Depth Interview guide after the conduction of the pre-test. This enhanced the quality of the responses that were obtained, which helped in answering the research questions. All ethical procedures were followed during pre-testing. Supervision The researcher also went to the field to supervise the work of the research assistants during data collection. Thus, ensure that data collection was carried out efficiently and ethically. He also explained certain issues that data collectors did not understand well. The recorded interviews were replayed after each session on the field which ensured that the interviews were conducted appropriately. Estimating Qualitative Study Trustworthiness The measures for ensuring qualitative trustworthiness according to Lincoln and Guba (1985) were applied in this study. The approach ensured credibility, applicability, consistency and neutrality. A prolonged interaction between the researcher and the researched was done. In addition, member checking was used to ensure credibility. The key informants were later contacted to verify certain responses given earlier during the interviews. More so, data triangulation was utilized by transcribing interviews verbatim, taking field notes into consideration. Furthermore, an audit trail was taken into consideration where a detailed description of the methods and procedures for data collection and analysis was provided to help ensure transferability. In addition, there was no prior relationship between the researched and the research team, thus there was neutrality. 34 University of Ghana http://ugspace.ug.edu.gh 3.10 Ethical Considerations Introduction The ethical considerations in this study included the study approval, informed consent, privacy and confidentiality, voluntary participation and withdrawal, risks and benefits, and results dissemination and they have been explained below. Study Approval Approval for the study was sought from the Ethical Review Committee of GHS, Research and Development Division in Accra. Formal permission was sought from the Sunyani Municipal Health Directorate as well as the gatekeepers of the selected health facilities and ghettos. An introductory letter was written by the head of department of Social and Behavioural Science to the health directorate. Inform Consent The informed consent which contained the purpose of the study, the various procedures involved, potential risks and benefits of participating in the study and other important things was adequately discussed with participants in a language they better understand. Participants received a detailed explanation of the study and were assured of its anonymous nature and all questions and sentiments pertaining to the study were answered and addressed appropriately to participants’ satisfaction before they were allowed to participate in the interview. Participants who agreed to participate in the study were given written informed consent and allowed to read and sign before interviewing them. Participation was voluntary and respondents were reminded of their liberty of refusal to answer any question when they feel uncomfortable as well to even withdraw from the study at any time if they wish. Confidentiality and privacy 35 University of Ghana http://ugspace.ug.edu.gh Before the interview begun, participants were assured of confidentiality. Names of participants were not requested. Each participant was given a pseudonym. Audio recordings were deleted right after they were transcribed. Collected data was stored on the computer of the researcher with restricted access. Participants were informed that their information given would be used solely for academic purposes and their information will not be shared with anyone. The results were presented and discussed without revealing the identities of the respondents. Interviews with participants were conducted outside their homes. A suitable place for them was be used. Interviews with key informants were conducted in their chosen places. Potential Benefits and Risk There was minimal risk involved in the study which was taking few minutes of participants’ time to answer the questions, which might be a form of distress to the participants. Results of the study could contribute to a robust policy that would ensure that the necessary services needed to address the healthcare needs of drug users are available and accessible to them to improve their health. Dissemination of Results The findings of this study were presented in a report and made available to the School of Public Health in the University of Ghana, Sunyani Municipal Health directorates, the health facility, among the drug users, various stakeholders and policy makers in the country’s health sector. Presentations were also held to present the findings of the study. The researcher also intends to use the findings to write manuscripts for publications in academic journals. Compensation The participants were informed that there will be no compensation given in this study. 36 University of Ghana http://ugspace.ug.edu.gh 3.11 Chapter summary The chapter three of the study presented the methodology of the study. Thirteen sections were presented in the chapter. Section one presented the philosophical worldview of the study and was followed by section two which presented the study design. Section three then presented an overview of the study area. Section four then moved on to talk about the study population including its inclusion and exclusion criteria. Issues concerning the sample size was captured in section five. Furthermore, section six presented the sampling method and section seven talked about the data collection method. Section eight then looked at the data analysis approach of the study. In addition, section nine presented the quality control of the study. Section ten then talked about the ethical consideration of the study. Sections eleven and twelve presented the study timelines and budget respectively and finally, section thirteen presented the summary of the chapter. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction Findings of the study in relation to the research questions and study objectives are presented in this chapter. The results are presented under the headings; Socio-demographic characteristics of participants, drugs that are being used among them, healthcare needs of the drug users, health seeking behaviour of the drug users and the social and economic factors influencing illicit drug use. 4.1 Socio-demographic characteristics of participants A total of 23 participants sampled from the ghetto and from the hospital records participated in the study. Fifteen participants were sampled from the ghetto including the gate keeper who served as a key informant for drug users at the ghetto and eight participants were sampled from the hospital records including one health worker who served as a key informant for drug users who had been diagnosed of any mental and behavioural disorders due to psychoactive substance use according to the ICD 10 Classification of mental and behavioural disorders, who are still using the substance. The age of drug users sampled from the ghetto ranged from 22 to 60 with a mean age of 41 years and that of the users sampled from the hospital records was between 31 and 45 with a mean age of 37.5. The ages for the key informants from the ghetto and the hospital were 37 and 36 years respectively. The key informant from the ghetto was a male and was one of the ghetto leaders who have been using drugs for about 20 years. The key informant from the hospital was a registered psychiatric nurse with five years working experience. Majority of the drug users were Christians with some level of education. Most of the drug users in the ghettos were unemployed while most of the users sampled from the hospital were 38 University of Ghana http://ugspace.ug.edu.gh employed. A very few of the drug users were married with majority being either single or divorced. Participants sampled from both the ghetto and hospital records had diverse residential status ranging from owning a house to sleeping at the ghetto (Table 1). Table 3:Demographic Characteristics of Drug Users Characteristics Number of Participants Ghetto Hospital Age Below 25 1 0 25- 34 2 2 35-44 5 4 45 and above 6 2 Sex Male 12 7 Female 2 0 Marital Status Single 8 2 Married 1 2 Divorced 5 3 Educational Level No Formal Education 1 4 Primary 1 1 JHS/SHS 12 1 Tertiary 0 1 Occupation Trader 2 2 Creaftmanship 3 3 Transport Industry 0 1 Unemployed 9 1 Residential Status Own House 0 1 Renting 1 0 Family House 8 6 Homeless/ Sleep in Ghetto 5 0 Religion Christianity 9 3 Islam 1 3 None 4 1 Years of Drug Use Below 10 4 1 10 to 20 4 6 21 and above 6 0 Key Informant 1 1 39 University of Ghana http://ugspace.ug.edu.gh 4.2 Drugs being abused Findings revealed that the common drugs being used in the Sunyani Municipality are cocaine, heroin, marijuana and tramadol. Alcohol is also being consumed a lot there. Majority of the drug users from the ghetto reported not to drink alcohol whereas majority of those sampled from the hospital reported alcohol use. The following quotes from the study participants illustrate the drugs that are being used among them: “It is the cocaine I use mainly. Then I smoke cigarette too. Once in a while, I smoke marijuana too but it is not something I like. For alcohol, I don’t drink” (42 years, Male, Ghetto). “Some people use tramadol. Others use cocaine, marijuana. Some people also will be smoking cigarette and others alcohol like akpeteshie (local gin), adonko bitters” (KII, 36 years, Female, Nurse). It was also found that majority of the drug users started by using marijuana and graduated to using cocaine. However, after using the cocaine, they do not like to use any other drug apart from the cocaine because of the effect they get from using it. Those that use other drugs still use the cocaine as their main drug. The quotes below from the key informant at the ghetto and one drug user indicates the above assertion: “For here, it is mostly the cocaine that people use. Recently too, the tramadol too they use it here. But for the junkies who have used the cocaine for long do not like the tramadol. Except the cocaine, the rock and tar, what the cocaine does, the tramadol cannot do” (KII, 37 years, Male, Ghetto). “For the drugs, its cocaine I use. I used to smoke marijuana but after I saw this, I don’t really like the marijuana again. I use it once a while. So, for now, it’s the tar and rock that I use” (22years, Female, Ghetto). In addition, all participants from the ghetto reported using drugs every day. Some reported using drug three times daily while others reported to use the drug twice daily. It was mainly the cocaine that was used on daily basis among them as presented in the following narratives: “For that one, it is like smoking cigarette, so in the morning, I use some. Maybe I might not use some in the afternoon but I have to use some in the evening” (50years, Male, Ghetto). 40 University of Ghana http://ugspace.ug.edu.gh “This is type of food that you never get satisfied eating it. As long as you have the money, you will keep using until you decide to sleep or don’t feel like taking it again. This is not like alcohol that you can drink and say that you are okay. No.” (50 years, Male, Ghetto). 4.2.1 Types of cocaine and heroin being used Findings showed that, there are two main types of cocaine and heroin that are being used in the Municipality. These are “rock” also known as crack cocaine and “tar”. From the data, it was found that the drug users combined the rock and tar and call it cocaine. However, from further probing, it was concluded that the rock is a form of cocaine which is crack cocaine and the tar is a form of heroin. These types come in different forms and have different effect on the users. The “rock” is in a solid form of the cocaine and it makes the users aggressive. There are two types of rock which are crystal and dirty rock. The crystal is shiny and blinks while the dirty rock is brown in colour. The tar is in powdered form and makes users calm. It also has two types which are Italian white and dirty tar. The Italian white is white in colour while the dirty tar is brown in colour. “This one (powered form) is called tar and the one I used on the pipe is called rock. But it is the rock that can make us do the bad things. If you learn how to use the rock and you use 10 today, you will want to use 20 the next time. And after using the 20, you will be craving for 30…When you take this (tar) you sleep. And when you use this (rock) you speed. If I use two of this (rock) and I am given a gun to kill you, I will not get any sympathy for you. I will do it. So, it is this (rock) that makes us do the bad things” (50 years, Male, Ghetto). “…One type is rock which is solid and another type is “tar” which is in powdery form. For the rock, you put it on a pipe and the pipe is in such a way that when you pull it, everything enters your mouth. So, you light matches on it and you pull it. When I pull it, I inhale it in my head when I do that, I feel that my head has become very heavy and make me very aggressive. For the rock, when you use it and you are there, it motivates you to go in for something that will make you get money to come in for more. So, my friend told me that if I don’t want to be aggressive, then I should use the “tar”. For the tar, we have one that we put on fuel and you light matches under it and chase it. That one is the chaser and we have another one that is mixed with marijuana and smoked. That one (tar) makes you calm. When you use it and get very high, you can sleep for about three hours…” (35 years, Male, Ghetto). 4.3 Healthcare need of drug users Findings showed that drug users have diverse healthcare needs. One of the commonest health challenges that the drug users at the ghetto reported is malaria and its accompanying 41 University of Ghana http://ugspace.ug.edu.gh symptoms like body weakness and headache, among others. This was expressed by the key informant who stated that: “The main health challenge we the junkies face is malaria, because we are down here with the mosquitoes. They always bite us and later lead to malaria but when the turkey also comes, then it brings all those sicknesses. But when you get some of the cocaine, you get a bit okay and covers the malaria. It makes you forget the malaria. But the moment the effect of the cocaine wears off, then the sickness comes again” (KII, 37 years, Male, Ghetto). This was also confirmed by one participant who also expressed that: “One disease that has been disturbing me a lot is malaria; even right now, I am suffering from malaria” (50 years, Male, Ghetto). Addiction was also found to be a health challenge among them. They reported symptoms of withdrawal due to addiction to the drugs they use and hence, indicated that it is a big challenge to them. One drug user explained this by stating that “The way I feel in my body when I don’t get some of the drugs, it is severe than any form of illness, because if I don’t use some the whole day, I can’t move. I will just be lying down. Even if they say the police is coming, I will not be able to stand up and run and I see that to be a sickness as well” (50years, Male, Ghetto). Another predominant health challenge faced by drug users at the ghetto was lung and breathing complications such as chronic coughing and coughing up black non-bloody phlegm. This is illustrated in the narratives below: “Right now that I am talking to you, if it becomes critical and I am told to run from here to that house (pointed to a house), I can’t. and if I walk for a short distance, I have to stop and squat for a while. I have been coughing too. I cough. And when I walk small, I feel pains in my ribs” (42 years, Male, Ghetto). “There is one sickness like pneumonia that affects us. You feel pains in your ribs. Because when you use the drugs for long, it wears off your rib bones. And it also affects your lungs. So, when the lungs become weak, you feel some pain in your rib section when breathing” (KII, 37 years, Male, Ghetto). 42 University of Ghana http://ugspace.ug.edu.gh “I have been experiencing pains in my ribs. When I cough, the phlegm is even black. It is not that serious though. Sometimes it comes and goes off. And I experience episodes of headache as well. It can pain me for a long time…” (53 years, Male, Ghetto). Some participants also reported cardiovascular complications such as abnormal heartbeat or rapid heart rate where one participant stated that: “I am suffering from HIV and I am on medication. But due to this life (drug use), I don’t adhere to the treatment well. I also experience episodes of headache and when I walk small, I feel tired and my heart starts beating faster” (47 years, Female, Ghetto). Results further indicated that gastrointestinal complication is a health challenge that is being experienced by these drug users at the ghetto where the key informant at the ghetto indicated that: “…You will feel so severe pain in the stomach and we have to rush you to the hospital” (KII, 37 years, Male, Ghetto). From the field note, other healthcare needs that were observed among the drug users at the ghetto include dry patches on the skin, cracked finger tips, tangentiality, which is a psychotic symptom and oral health issues such as decayed and lost teeth, among others. It was also observed that an important social factor that undermines the health of most of the drug users was homelessness. The field note further showed that one drug user from the hospital also had oral health issues and another participant had puffy face and swollen extremities. Most of the drug users who reported that they have no health challenges were from the hospital where one indicated that: “It is just the normal sickness. Maybe headache and others and it come for a short while and go. I usually see it as stress related” (33 years, Male, Hospital). Another drug user confirmed this by stating that “I really don’t face any challenges it’s just about two days now that I have not been able to sleep very well” (45 years, Male, Hospital). 43 University of Ghana http://ugspace.ug.edu.gh Findings showed that almost of the drug users from the ghetto reported a poor health status as compared to those from the hospital who reported that their health status was good and they feel healthy and this is illustrated in the narratives below: “I am not healthy. Not healthy at all” (47 years, Female, Ghetto). “For now, my health status is very good. Previously, it was bad but after I visited the hospital, it is good now” (33 years, Male, Hospital). The results of the study again showed that all the drug users at the ghetto reported that they are not comfortable with the situation they find themselves in (drug use) and want help so that they can stop. This is illustrated from excerpt from a participant who said: “Right now, I seriously want to stop taking the drugs. I am tired of it. Because as long as I use it, I keep on falling sick and not able to stay healthy” (47 years, Female, Ghetto) and was also supported by another excerpt where the participant stated that “for now, what I really need is to be able to stop using the drugs. I want to be free from this life. I want to stop using them” (53 years, Male, Ghetto). 4.4 Health seeking behaviours This section has been categorized into two themes namely health seeking practices and determinants of seeking illness care. The theme on health seeking practices constitutes the drug users’ illness perception, illness identification and their treatment practices. 4.4.1 Health seeking practices Findings showed that drug users at the ghetto mostly have a common perception about illnesses that they usually experience. It was shown that they perceive illness as withdrawal symptoms which they call ‘turkey’ as a result of addiction to the drugs they use. This was explained by one drug user who said: “Whenever I feel sick, I see it to be ‘turkey’. So, when I get some of the drug to use, then it stops. But after some few minutes that the effect of the drug wears off, then those symptoms come back. So, it doesn’t make me feel that its sickness. I see it to be ‘turkey’. It happened to me at some point in time and I got admitted at the hospital” (22 years, Female, Ghetto). Another excerpt below confirms the illness perception of the drug users at the ghetto: 44 University of Ghana http://ugspace.ug.edu.gh “I have never been to the hospital. I have a perception that when not feeling well, then its “turkey”. But usually, after using the drug (cocaine), I feel alright” (35 years, Male, Ghetto). Findings further showed that, the drug users have a similar way of identifying their illnesses. They reported that, they are able to identify that they are sick when symptoms of the sickness persist after using the drugs (mainly cocaine and heroin). They reported that, they first see their sickness symptoms as ‘turkey’ or withdrawal symptoms. This is illustrated by the excerpts below: “Hmm. For now, when I am not feeling well, I see the symptoms to be severe than what I experience when ‘turkeying’. Right now for instance, I have cold and I thought it was ‘turkey’. When I came, they were all saying its ‘turkey’ but after using the drugs, it’s still there. Then I know it is not the ‘turkey’ but I’m sick” (22 years, Female, Ghetto). “The first thing I think of is because I have not been able to get some of the drug to use. So after using it (cocaine) and I still feel unwell, then I know that I am sick. Then the man will rush to the pharmacy to get some medicines for me to take” (26 years, Male, Ghetto). However, drug users from the hospital are able to identify it quickly when they are sick. One participant explained it by saying that: “For that one, I am able to see. That is if any part of my body is aching, I notice it. The main difference is that with this one, it is in the mind. But if it is something like I am visiting the toilet too many times, I can see something is wrong. Or if my vomit is yellow, I can see that something is wrong with me.” (38 years, Male, Hospital). Findings showed that drug users have diverse health seeking practices. They resorted to using different sources and means of healthcare and sometimes simultaneously use multiple sources of care. Due to the reported illness perception and identification, the first treatment source they use when experiencing symptoms of ill health in the ghetto is to use drugs (mainly cocaine and heroin). The excerpts below illustrate the findings: “If I will fall sick, then maybe it is something like headache, and the moment I get the cocaine to use, it will be gone. So, I don’t take anything (medicine) when I have those headaches. Even when I have sustained an injury and being given money to go to the hospital, I will just come here and use the drug (cocaine) and don’t go to the hospital and eventually, I get healed” (35 years, Male, Ghetto). 45 University of Ghana http://ugspace.ug.edu.gh “Whenever I don’t feel well, I go to the ghetto. I don’t go to the hospital and don’t go to any pharmacy. I come straight to the ghetto to get some drugs (cocaine or heroin) to use” (40 years, Male, Ghetto). The use of local pharmacy appeared to be popular among the drug users from the ghetto, especially when they use the cocaine and still feel symptoms of ill health. “I buy medicine from the pharmacy. When I’m not feeling well and use the drug and still not feeling well, then I go and buy the medicine from the pharmacy” (50 years, Male, Ghetto). “I don’t go anywhere. I just take the drugs (cocaine or heroin). Sometimes I go to the pharmacy to buy medicine, but I use the drugs (cocaine or heroin) more than the medicine that I buy from the pharmacy” (26 years, Male, Ghetto). However, those from the hospital mainly reported to use the hospital or clinic as their first point of care when they are experiencing symptoms of ill health. Some of them also reported to use the local pharmacy. The following quotes illustrate the finding: “I go to the clinic to get some malaria medication or some of the injection. I used to go to Dr. Asare’s clinic but when I went there recently, he said it is because of the alcohol I am drinking then I came to the government hospital” (38 years, Male, Hospital). “Sometimes I come to the hospital. Sometimes I go to the pharmacy to buy medicine” (47 years, Male, Hospital). Some drug users from both the ghetto and hospital also reported using religion and spirituality as a source of treatment sometimes which as illustrated below: I like to go to the hospital. But when it is not anything serious, I go to the prayer camp to pray. They can give me anointing oil and other things and I get better” (31 years, Male, Hospital). Sometimes too, I just fetch water and pray on it and drink it and I will be fine. If you ask a lot of people, they will tell you that I am a wizard” (54 years, Male, Ghetto). 4.4.2 Determinants of seeking illness care Findings showed that, the determinants of health seeking varied among the drug users depending on the choice of treatment source. The main determinants that were reported are severity of illness, ease of communication, perceived benefit, cost of care and cue to action. Reasons that accounted for lack of care seeking were lack of knowledge about the condition 46 University of Ghana http://ugspace.ug.edu.gh and where to seek care, cost involved and the feeling that the condition was not serious enough to merit treatment. Perceived benefit Findings showed that drug users’ health seeking behaviour or choice of treatment is informed by the benefit they stand to gain by taking a particular action. This makes majority of them choose to use more drugs when not feeling well, while others also go to the pharmacy or visit the hospital. The illustrations below indicate how the benefit they stand to gain by performing a particular action influences their illness treatment practices: “I have been coughing. You see right now my voice is not clear. I feel pains within and I will be yawning frequently. Feel pains in my calf. But usually when I get the drug (cocaine). It all vanishes. After the effect of the drug wears off, then it comes back. But as long as I get it to use, I am ok. Let’s say even when I’m seriously sick, I don’t go to the hospital. I have never been to the hospital” (26 years, Male, ghetto). “When I’m not feeling well and use the drug and still not feeling well, then I go and buy the medicine from the pharmacy” (50 years, Male, ghetto). “The best for me is the hospital or a nearby clinic…I see that place to be the best for me” (33 years, Male, hospital) Severity of illness Another determinant of illness treatment source was reported to be severity of illness. Here, drug users reported that they take actions based on how severe the illness is. The illustrations below indicate how the severity of illness influences their decision and illness treatment source: “We don’t go to the hospital. If someone’s condition is serious, we get them some paracetamol or amoxicillin or penicillin then we buy it for the person. When the person takes them, they get to normal a bit…” (KII, 37 years, Male, ghetto). “I like to go to the hospital. But when it is not anything serious, I go to the prayer camp to pray. They can give me anointing oil and other things and I get better” (31 years, Male, hospital). “I don’t think of going right away. I don’t usually see it to be serious so if I try managing it in the house and it doesn’t go, then I see it is serious and I take it to the hospital” (60 years, Male, ghetto). 47 University of Ghana http://ugspace.ug.edu.gh Cues to action Results further showed that there were strategies that activated readiness of a drug user to seek care from a particular source. Witnessing the death of a colleague or critical health condition for instance was found to have an influence on a drug user’s health seeking behaviour. The key informant at the ghetto explained this well by stating that: “If someone will go to the hospital, there is one sickness like pneumonia that affects us. You feel pains in your ribs. Because when you use the drugs for long, it wears off your rib bones. And it also affects your lungs. So, when the lungs become weak, you feel some pain in your rib section when breathing. So, when it happens and you don’t rush you to the hospital, you will die” (KII, 37 years, Male, Ghetto). Ease of communication The ease at which they were able to communicate with the healthcare provider also influenced their choice of health seeking. At the pharmacy shop for instance, they indicated that they are able to communicate well with the shop attendant and the attendant give them the medicine they want. One drug user explained well by indicating that: “So, when the sickness comes again, then I know these are the medicines I am supposed to take. So, I still have the box of the medicine with the name, when I go to the pharmacy, I just tell them the name of the medicine and they give it to me” (50 years, Male, Ghetto). Barriers Results showed that, for most participants, the main barrier to health seeking at the hospital was the cost involved. Most of them were not patronizing the National Health Insurance and also reported that they do not have the financial resources to cater for the charges involved in seeking treatment at the hospital. The illustrations below indicate how cost served as a barrier to health seeking at the hospital: “I prefer going to the hospital but I don’t have health insurance and also I don’t have any money on me to use to pay for the cost involved. And I can’t go to the hospital without any money to pay for the cost involved” (22 years, Female, Ghetto). 48 University of Ghana http://ugspace.ug.edu.gh “…no, I don’t because I don’t have money to take to the hospital. Recently, I went to one newly opened hospital and I was rejected to go to the big hospital. And I was given a bed there. They asked me which of my family members is coming and no one was there because they are tired of me. So, when that happened, I wasn’t attended to at the hospital so I got off the bed and headed home” (42 years, Male, Ghetto). Knowledge about the appropriate place to seek treatment was also found to be a barrier to health seeking. It was found that, even though all the drug users reported that they want to stop drug use, they are unable to stop because of the withdrawal symptoms. They however do not know where to seek treatment for the drug addiction. The key informant at the ghetto explained it well by stating that: “…And a lot of people also don’t know where to go to in order to be able to stop using the drugs. A lot don’t know” (KII, 37 years, Male, Ghetto). Fear of being arrested was also reported to be a barrier to health seeking at the hospital for both addiction and other physical conditions. One drug user at the ghetto reported that he is scared that he might be arrested when he goes to the hospital to seek treatment and as a result, doesn’t go at all, thus he explained the following statements: “Sometimes too I think about it and get scared that maybe I might be arrested because of the drug issue. So, I am a little bit scared sometimes. If not for that, I would have gone there long ago” (50 years, Male, Ghetto). 4.5 social and economic factors influencing drug use The social factors that were associated with drug use in the Municipality includes peer pressure, sense of euphoria or feeling ‘high’, stressful life events, among others. With peer pressure as a social factor influencing drug use, it was found that many of them were introduced to drug use by their friends. This is illustrated by the quotes below: “Friends also have influence on me. my friends know how to drink so whenever I walk with them, I end up drinking” (31 years, Male, Hospital). “It was through friendship that I was introduced to the cocaine. He told me marijuana has less effects. Its cocaine that can make you high for a very long time” (35 years, Male, Ghetto). 49 University of Ghana http://ugspace.ug.edu.gh On the issues of sense of euphoria as an influencing factor of drug use, majority of the drug users reported that they started using the drugs and still use it just to feel good. That is, to get that feeling of highness after using a psychoactive substance. This was well explained by the key informant from the ghetto who indicated that: “With this, it is just like some sort of feeling… It is just a feeling that we have brought to ourselves so you don’t look well when you don’t get it. Without it in the body, you don’t feel alright… it is because of the feeling. Like you drinking alcohol and boozing or smoking weed to get high. That’s it” (KII, 37 years, Male, Ghetto). This was also supported by another user from the hospital who indicated that using the drugs makes you feel happy when he stated that: “It only makes you happy. That is all” (33 years, Male, Hospital). Stressful life event was also reported as a social factor that influences drug use in the Municipality. It was found that some people go through some sort of stressful life event that makes them sad and worried and they in tend use the drug as a coping strategy. This is illustrated by the excerpts below. “My mother died and it made me very sad. So whenever I remember, then I go and drink it and now, I have become used to it. Soon after the death of my mother, my father also died and it spoilt the issue…when I drink it, I forget my sadness. When the effect of the alcohol goes off, the sadness comes back and I drink again then it goes off” (31 years, Male, Hospital). “When I was deported, I was always sad and worried and through a friend, I got to know of the cocaine and tested it and realised the effect was higher than the wee then I started using it. So it’s the cocaine I have been using one two one two… For mine, it’s how I was deported. All my properties remained there. So it worried me a lot and as results, I started using the drugs… so when I use the drug, I forget my worry and sadness. But after the effect is gone down, I remember it again then I go in for more” (50years, Male, Ghetto). Other social factors that were found to influence drug use in the Municipality were advertisement by the media, anxiety, accessibility and performance enhancement. This was explained well by the key informant from the hospital who stated that: 50 University of Ghana http://ugspace.ug.edu.gh “Some is as a result of the advert on the radio and television. That is where it starts then gradually; they end up using the hard drugs and others things. Some of them do not know those drugs. But when they hear adverts like this alcohol is good for sexual performance and others, they start drinking and later, they end up using the drugs like tramadol, cocaine and the rest. So the many advert has a role to play in it. Some too is as a result of fun and excitement. That is where it starts for some people. Their colleagues regard drinking or smoking to be the new thing and they must do it. Then gradually, they find themselves using other hard drugs too. Some people too suffer from anxiety and they start using alcohol to be able to talk in front of people and gradually, they end up using other drugs as well. Friends also have a major role to play here. They influence their friends into such lifestyle. Some too have some social problems and keep them. They don’t share them and tend to use these drugs to be able to cope with them and end up becoming a problem for them” (KII 36 years, Female, Nurse). Results also showed that, the economic factors that influences drug use in the Municipality is the ability to work hard. Drug users reportedly use the drug to enhance their ability to work hard. This was explained well by a drug user who stated that: “If I don’t use it, I am not able to work. I don’t have the energy to do my carpentry work so I have to use it to be able to do it… I want to stop but as I told you earlier, because of the hard work, I am not able to stop because I don’t get anything to substitute it with this that will enable me do the hard work” (60 years, Male, Ghetto). Another important factor influencing drug use in the Municipality was addiction. It was found that these drug users are all addicted to the drugs and therefore, always go in for more drugs to sustain their dependency. The quotes below illustrate the finding: “And with all this that we do, there are times we regret but it is something that when you start, it is not easy to stop. Because craving for it is very serious. If you don’t get some to you, you feel very uneasy in your whole body and don’t know what to do to yourself. Even your sleeping becomes problematic” (50 years, Male, Ghetto). “At first, I wasn’t turkeying without it. So I didn’t use it all the time. But now, I get turkey so when I wake up and don’t get some to use, then I feel uneasiness in my body. Anytime I have money, I come here and use all on drugs” (22 years, Female, Ghetto). 4.6 Conclusion of results The study indicated that drug users were using different types of drugs depending on the effect of the drug. They are being faced with several health challenges, which undermine 51 University of Ghana http://ugspace.ug.edu.gh their health status. Nevertheless, they rarely use formal healthcare seeking sources. Their healthcare seeking practices are accounted for by diverse determinants. Several factors including social and economic factors account for drug use in the Municipality. 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.0 Introduction This chapter discusses the key findings of the study according to the specific objectives of the study. The section starts by discussing the drugs that are being used in the Municipality, then moves on to discuss the healthcare needs of the drug users. It then moves on to discuss the health seeking behaviour of the drug users and finally discusses the socio and economic factors influencing drug use in the municipality. 5.1 Drugs being used Findings of this qualitative study indicate that the main drugs that are predominantly used among the drug users are crack cocaine and heroin. Even though the participants know the heroin to be a type of cocaine, the nick name they use for it is ‘Tar’ and the detailed description given helped the researcher to identify it to be heroin. Findings on the drugs being used is consistent with other studies that reported similar drugs being used (Corradi-Webster & Gherardi-Donato, 2016; Oser et al., 2012 & Robbins, Wenger, Lorvick, Shiboski, & Kral, 2010). 5.2 healthcare needs of drug users Findings show that drug users face a lot of health challenges and have diverse healthcare needs, the commonest being addiction and malaria. The plausible cause of malaria among the drug users is their geographical location. They are located at the ghetto which is surrounded by bushes and stagnant waters, which are breeding places for mosquitoes, hence the high rate of malaria among them. This finding is similar to a study conducted in Vietnam by Chau et al. (2002) who also reported malaria among drug users. Addiction was also found to be a major healthcare need of drug users. Due to the addiction, drug users always crave for the 53 University of Ghana http://ugspace.ug.edu.gh drugs and this resulted in withdrawal symptoms anytime they make an attempt to quit. The finding is similar to other studies that found addiction as a healthcare need among drug users accompanied by withdrawals when they make an attempt to quit (Silva & Nappo, 2019; Soltesz, 2019). Another healthcare need of the drug users is lung and breathing complications. This could be due to smoking of the drugs and the impurities in the drugs they constantly use. This finding is consistent with studies conducted by Hanks et al. (2002) and Gordon, Conley, and Gordon, (2013) who also reported pulmonary and thoracic complications among illicit drug users. The presence of cardiovascular complications was also found to be a health challenge faced by the drug users. Similarly to the findings of this study, Hanks et al. (2002) and Enevoldson (2004) also reported cardiovascular complications among drug users in their study. Findings further show that the drug users face gastrointestinal complications. This findings is consistent with findings by Wurcel, Merchant, Clark, and Stone, (2015) who also reported in their systematic review that drug users experience gastrointestinal complications. O’Brien et al. (2015) also reported gastrointestinal complications among drug users. Skin complication was also found among the drug users and this finding is consistent with the findings by Wurcel et al. (2015) and Liu, Lien, and Fenske, (2010) who also reported skin complications among drug users. The presence of oral healthcare need was also found in this study. Most of the drug users had poor oral hygiene and lost teeth. This could plausibly be due to addiction to the drugs such as heroin and cocaine which is known to result in oral health challenges among drug users. This finding is consistent with other studies who also found oral health challenges among drug users (Robbins, Wenger, Lorvick, Shiboski, & Kral, 2010; Reece, 2007; Metsch et al. 2002). 54 University of Ghana http://ugspace.ug.edu.gh Almost all the drug users in the study also reported a low and poor health status and quality of life which is consistent with the findings by O’Brien et al. (2015) who also reported in their study that drug use is associated with a self-reported poor health status and lower perceived quality of life. 5.3 health seeking behaviours of drug users Findings of this qualitative study showed that most drug users are not able to identify it when experiencing ill health. This could be due to the withdrawal symptoms which are similar to that of the symptoms of the ill health they are experiencing and hence, they regard it as withdrawal and not a physical ill health. Some of them are able to identify that they are suffering from a physical ill health only after they have used the drug and symptoms of the ill health still persist. This practise can lead to delay in accessing adequate treatment which can result in tremendous health effects among them and in the worst case, can lead to death. Finding further indicated that the drug users have diverse health seeking practices. They seek health from different sources which followed a pattern until the problem is solved. This finding is similar to a study conducted by Asampong et al. (2015) who also found that participants resorted to using multiple sources with a pattern of seeking healthcare from a succession of types of healthcare provider until the problem is solved. Most of the drug users’ first source of seeking health when they experience symptoms of ill health is to go to the ghetto to use more drugs. This could plausibly be due to the symptoms of the physical ill health which is mostly regarded as withdrawal symptoms and hence, call for more drugs to be used. The next line of health seeking source was the use of local pharmacy. Drug users were comfortable going to the local pharmacies because they are able to communicate well with the shop attendant and are being given the medicine of their choice at those places. The use of religion and spirituality was also found to be used as health seeking practices by some 55 University of Ghana http://ugspace.ug.edu.gh individuals. Formal healthcare was found to be sought from private clinics and government hospitals. However, the drug users rarely seek healthcare from those places. Though participants’ characteristics such as level of education, income, sex, marital status, among others are important determinants of health seeking behaviours, the study focused on service and illness characteristics. Findings showed that determinants of health seeking practices varied across individuals but mostly influenced by the illness characteristics and service provided. Subsequent choice of health care was determined by perceived benefit of treatment, severity of illness, ease of communication with healthcare provider and cues to action. The barriers to formal healthcare seeking included; cost of healthcare, knowledge about condition and where to seek appropriate care and fear of being arrested due to drug use. Severity of illness was found to be an important determinant of health seeking practices. This was the belief that certain conditions were not serious enough to merit treatment at the appropriate source. This could possibly be due to the low level of education about conditions among the drug users and this could result in delay in accessing appropriate healthcare which could affect prognosis negatively. The common practise of further drug use as a means of staying healthy or treating symptoms of physical ill health was motivated by their perceived benefit. This is mainly because symptoms of the ill health were not felt after using the drugs and experience it again when the effect of the drug is diminishing and they tend to use more. This practise among them could be influenced by the low level of education among them about specific health conditions that they face and the appropriate health seeking practices to adopt, probably pointing out the need for health education among them to improve their health seeking practices. 56 University of Ghana http://ugspace.ug.edu.gh The ease at which they were able to communicate with healthcare provider was also found to influence the health seeking behaviour of the drug users. It was found that they mostly choose the local pharmacy because they easily communicate with the attendant there and they get the medication of their choice. With the formal healthcare, some of them were unable to go due to the discrimination and marginalisation drug users experience. Cue to action also influenced their health seeking behaviour. On this as an influencing factor, the drug users seek healthcare for specific conditions due to past experience or observing a colleague suffer or die from that same condition. This therefore motivated them to seek formal healthcare when they also experience similar symptoms or condition. These findings on determinants of health seeking behaviours were similar to the findings of Asampong et al. (2015) who also reported in their study that severity of illness, perceived benefit of treatment, ease of communication are part of the determinants of health seeking behaviours among participants. The barriers to formal health care seeking that were found in the study are cost, lack of knowledge and fear of arrest. On the issue of cost as a barrier to formal healthcare seeking, majority of the drug users reported that they are unable to seek healthcare from the hospital due to the perceived high cost of healthcare cost at the formal health care facilities. Nevertheless, there was low patronage of National Health Insurance Scheme among them. This finding on cost of healthcare as a barrier to formal healthcare seeking is similar to the findings of the study conducted by Menon, Sarkar, and Kumar, (2015) who also found cost as a barrier to healthcare seeking among respondents. The study also found that lack of knowledge on medical condition and appropriate place to seek care was also a barrier to formal health seeking for ill health. This could possibly be due to the low level of health education on specific health conditions and appropriate health seeking sources among the drug users, possibly an indication that there is the need for health education among them to improve their health seeking practices. This finding on knowledge as a barrier to formal 57 University of Ghana http://ugspace.ug.edu.gh health seeking was similar to the findings in a study conducted by Menon et al. (2015) who also reported knowledge as a barrier to formal healthcare seeking. Perceived discrimination was also found as a barrier to formal health seeking among the drug users. It was found that some of them are scared of being arrested when they go to the hospital. This could plausibly be due to the current laws in Ghana where drug use is considered as a criminal justice issue. This finding on discrimination as a barrier to formal healthcare seeking is similar to a study conducted by Allen, Call, Beebe, Mcalpine, and Johnson, (2018) who also found that discrimination was a barrier to formal health seeking among the participants. 5.4 Social and Economic factors influencing drug use Findings of this study also showed that the social factors that influence drug use are peer pressure, sense of euphoria or feeling ‘high’, stressful life event, among others. Many of the participants were introduce to drug use through their peers. This could possibly start with experimental use of the drugs as introduced by peers or the attractive look of the drugs that make people go in to try them and eventually use them continuously. The sense of euphoria or feeling ‘high’ effect that comes along with drug use was also an influencing factor. Stressful life events were also found to be an influencing factor of drug use. This could be as a result of using the drugs as a means of coping with the stressors and eventually, leads to addiction and dependence. These findings on social factors influencing drug use is similar to the finding of a study conducted by Alhyas et al. (2015). Other social factors that were found to influence drug use are media advertisement of alcohol, use of drugs to enhance sexual performance, anxiety and accessibility. The media constantly advertises alcohol for several reasons, especially sexual enhancement. This could possibly be an influencing factor of drug use by serving as a stepping stone to gradually use high substances to get the desired effect. Anxiety could also be an influencing factor of drug use in that it gives the users some sort of courage to be able to do things they were anxious about like public speaking, among others. 58 University of Ghana http://ugspace.ug.edu.gh On economic factors that influence drug use, the study found that drugs were used to enhance work hard. This could possibly be due to people wanting to increase their productivity at work. They intend use drugs so that they can work for a very long time without getting tired. 5.5 Limitation of the study 1. There was a challenge in finding a quiet suitable place to conduct the interviews. Some participants could be distracted slightly during interviews by other colleagues. This limitation, however, did not influence the quality and credibility of data obtained. 2. The researcher was unable to confirm the health challenges reported by the drug users by conducting the necessary laboratory tests to know the exact medial conditions due to the study design. 59 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.0 Introduction This chapter presents the conclusion and recommendation of the study. Three sections are presented in the chapter. Section one presents the introduction of the chapter. Section two presents the conclusion of the study. The third section presents the recommendation of the study. 6.1 Conclusion The drugs that are mainly used among the drug users are crack cocaine, heroin, marijuana and tramadol with cocaine and heroin being the predominantly used drugs among the drug users. The crack cocaine makes them aggressive while heroin on the other hand makes them calm. Respondents had diverse healthcare needs which can be categorized into mental, physical and social healthcare needs. The main mental healthcare need of the drug users was addiction. They were addicted to the drugs and go through severe withdrawals without the drugs. With the physical healthcare needs, they reported facing health challenges such as malaria, lung and breathing complications, skin complications, cardiovascular complications and gastrointestinal complications. They face social and health care challenges such as discrimination, homelessness and joblessness and they all reported a poor health status and low perceived quality of life. Findings also indicated that respondents usually see symptoms of ill health to be symptoms of withdrawal and mostly go in to use more drugs even when they are sick. They are able to identify that they are sick usually after they use drugs and still don’t feel well. After they identify sickness, the first point of seeking healthcare is the local pharmacy. They usually go 60 University of Ghana http://ugspace.ug.edu.gh to the hospital to seek formal treatment when they see the sickness to be severe. A few of them also use spirituality as a source of treatment. The determinants of their health seeking practices were severity of the illness, perceived benefit of treatment practices, ease of communication with healthcare provider and cues to action. The barriers to health seeking included cost of healthcare, lack of knowledge on condition and appropriate source to seek treatment and perceived discrimination. It was also found that, the social factors that influence drug use were peer pressure, sense of euphoria or feeling ‘high’, stressful life event, advertisement by the media, performance enhancement, easy access and anxiety. The single economic factor that was found to influence drug use was ability to work hard to increase productivity. Addiction was also found to be a medical factor that influenced drug use. 6.2 Recommendations Recommendation for Ghana Health Service and Ministry of Health: 1. Health services should provide a holistic care for drug users so that all their healthcare needs will be addressed. 2. Massive education should be provided: a. For drug users to improve their knowledge on their health challenges and where to seek treatment b. For the general population to better understand addiction and how to make social support system available for these drug users and also to reduce discrimination and stigmatization c. For all healthcare providers to enhance their knowledge and skills and make them aware of the healthcare needs of the drug users and how to provide the needed healthcare services to them 61 University of Ghana http://ugspace.ug.edu.gh 3. Addiction treatment centers should be institutionalized in our existing hospitals to treat drug addiction. 4. There is a need to decriminalize drug addiction so as to remove the fear of being arrested in order to promoted access to health care for drug addicts. 5. Awareness should be created among the drug users on the need to enroll on National Health Insurance Scheme as this could improve access to quality needed healthcare among them. Recommendation for further research Future studies should be conducted on the topic using other research designs and methods to confirm the actual health challenges drug users face. For example, a study that will take blood samples or conduct laboratory tests to confirm the specific health challenges. Further research can also use mixed method to quantify and know the prevalence of the drug use and also know other factors associated with drug use as this study design (qualitative) doesn’t allow the researcher to determine causality or association using statistical methods. 62 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abuse, S. (2016). 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Clinical Infectious Diseases, 61(12). https://doi.org/10.1093/cid/civ689 70 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix 1: Participant information sheet School of Public Health College of Health Sciences University of Ghana Information Sheet Project Title: Health seeking behaviours among drug users in the Sunyani Municipality Institutional Affiliation Department of Social and Behavioural Sciences School of Public Health, University of Ghana Legon Background Personal Introduction The principal investigator of this study is Abdul Cadri, a Master of Public Health student of School of Public Health, College of Health Sciences, University of Ghana. I am conducting a study on Health Seeking Behaviours among Drug Users in the Sunyani Municipality. This research is for academic purposes and a requirement for the award of Masters’ Degree in Public Health. This study is being supervised by Dr. Collins Ahorlu of Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana. 71 University of Ghana http://ugspace.ug.edu.gh Procedure Taking part in this study will take about 20 minutes of your time and we expect your honest response in answering of the questions. The questions are about your experiences and health seeking behaviour. The ethical considerations in this study will include the study approval, informed consent, privacy and confidentiality, voluntary participation and withdrawal, risks and benefits, and results dissemination and they have been explained below. Study Approval Approval for the study will be sought from the Ethical Review Committee of GHS, Research and Development Division in Accra. Formal permission will be sought from the Sunyani Municipal Health Directorate as well as the gatekeepers of the selected health facilities and ghettos. An introductory letter will be written by the head of department of Social and Behavioural Science to the health directorate. Informed Consent The informed consent which will contain the purpose of the study, the various procedures involved, potential risks and benefits of participating in the study and other important things will be adequately discussed with participants in a language they better understand. Participants will receive a detailed explanation of the study and assured of its anonymous nature and all questions and sentiments pertaining to the study will be answered and addressed appropriately to participants’ satisfaction before they are allowed to participate in the interview. Participants who will agree to participate in the study will be given written informed consent and allowed to read and sign before interviewing them. 72 University of Ghana http://ugspace.ug.edu.gh Participation will be voluntary and respondents will be reminded of their liberty of refusal to answer any question when they feel uncomfortable as well to even withdraw from the study at any time if they wish. Risk and Benefits There is minimal risk involved in the study and may usually come as taking few minutes of participants’ time to answer the questions, which might be a form of distress to the participants. Results of the study could contribute to a robust policy that would ensure that the necessary services needed to address the healthcare needs of drug users are available and accessible to them to improve their health. Right to Refuse/Voluntary Participation Your participation is voluntary and you can withdraw at any time without consequences. Even though we would be very grateful if you decide to partake in this study and answer all the questions sincerely, neither you nor the study will be affected if you decide not to take part. Anonymity and Confidentiality Please do not provide any identifying information during the interview. Your responses will be confidential and your identity will not be known to anyone. This will be ensured by assigning codes to you. The recorded interview will be deleted right after transcription and transcription will be kept in a locked cabinet after data analysis and can be accessed by only the Principal Investigator and will be destroyed when it is no longer relevant to the research – after five years. Information from this research will be used solely for this study and any publications that may result from this study. Your rights as a Participant 73 University of Ghana http://ugspace.ug.edu.gh This research will be reviewed and approved by the Ghana Health Service Ethics Review Committee. Your right as a research participant will not be affected in any way for taking part in this study. Compensation There will be no compensation or fee paid to participants for agreeing to participate in this study. Before taking consent If you have any questions, kindly ask or for further clarifications, please don’t hesitate to contact the Principal Investigator: Name: Abdul Cadri Address: ku 87, Kutre No 2, Berekum, Brong Ahafo Region Telephone number: 0202928766 Email: abdul20c@yahoo.com In case of any ethical concern, you can contact the Ethics Administrator, Ms. Hannah Frimpong, GHS/ERC on 0243235225/0507041223 Consent form PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in a language I understand (Asante 74 University of Ghana http://ugspace.ug.edu.gh Twi). I fully understand the contents and any potential implications as well as my right to change my mind (ie withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant………………… ID Code …………………………….. Participants’ Signature ………OR Thumb Print………… OR Mark (Please specify)…………. Date:…………………………………. INTERPRETERS’ STATEMENT I interpreted the purpose and contents of the Participants’ Information Sheet to the afore named participant to the best of my ability in the (Asante Twi) language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter…………………………… Signature of Interpreter……………………….. Date:……………………… Contact Details 75 University of Ghana http://ugspace.ug.edu.gh STATEMENT OF WITNESS I was present when the purpose and contents of the Participant Information Sheet was read and explained satisfactorily to the participant in the language he/she understood (Asante Twi) I confirm that he/she was given the opportunity to ask questions/seek clarifications and same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name:………………………… Signature……………. OR Thumb Print ……….... OR Mark (please specify)……………….. Date:…………………………… INVESTIGATOR STATEMENT AND SIGNATURE I certify that I have explained the procedure to be followed in this study to the respondent(s) in the language (Asante Twi) they best understand and they have agreed to participate in the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 76 University of Ghana http://ugspace.ug.edu.gh Appendix 2: Interview Guides 1. Interview guide for Drug Users in the Ghetto Introduction I am conducting a study to assess the Health Seeking Behaviours among Drug users in the Sunyani Municipality. I will be grateful if you could spend a little of your time to complete this interview with me. There are no right or wrong answers. Any information provided is private and confidential. This study is only for academic purposes. Your participation in this study is entirely voluntary. Please feel free to answer the questions below. Thank you. Participant Code……………. Date of interview……………… Demographics The following questions will be about your demographics characteristics (age, marital status, etc) 1. How old are you? ………… 2. Sex 3. What is your ethnicity? 4. What is your marital status? 5. Do you have children? How many children do you have? 6. What is your highest educational level? 7. What is your occupation 8. Where do you live? 9. Which religion do you belong to? 1 Christian [] 2. Muslim [] Drugs being used 10. Tell me the drug(s) you use. How often do you use it/them? 77 University of Ghana http://ugspace.ug.edu.gh 11. Why do you use those particular drugs? 12. How long have you been using them? 13. Tell me the benefits you get from using them. Healthcare needs 14. Tell me how you see your health status to be currently 15. What health challenges have you been experiencing in the past one month? Which is most serious? 16. Could you tell me the symptoms of illness you have facing? What do you think is the cause? 17. How do you know if you are not feeling well? 18. Tell me about the health services you need now. What are you doing to satisfy those needs? Health seeking behaviour 19. Where do you go or whom do you consult when you are facing a health challenge? Why that choice? 20. What makes you go to the hospital? What stops you from going? 21. Tell me what you do to ensure you don’t fall sick. Factors influencing drug use 22. Tell me why you still use drugs 23. What stops you from using drugs? 24. Where do you get money to buy the drugs? 78 University of Ghana http://ugspace.ug.edu.gh 2. Interview guide for Drug Users who visit the hospital Introduction I am conducting a study to assess the Health Seeking Behaviours among Drug users in the Sunyani Municipality. I will be grateful if you could spend a little of your time to complete this interview with me. There are no right or wrong answers. Any information provided is private and confidential. This study is only for academic purposes. Your participation in this study is entirely voluntary. Please feel free to answer the questions below. Thank you. Participant Code……………. Date of interview……………… Demographics The following questions will be about your demographics characteristics (age, marital status, etc) 1. How old are you? 2. Sex 3. What is your ethnicity? 4. What is your marital status? 5. Do you have Children? How many children do you have? 6. What is your highest educational level? 7. What is your occupation? 8. Where do you live? 9. Which religion do you belong to? Drugs being used 10. Do you still use drugs? 11. Tell me the drug(s) you use. How often do you use it/them? 12. Why do you use those particular drugs? 79 University of Ghana http://ugspace.ug.edu.gh 13. How long have you been using them? 14. Tell me the benefits you get from using them. Healthcare needs 15. Tell me how you see your health status to be currently 16. What health challenges have you been experiencing in the past one month? Which is most serious? 17. Could you tell me the symptoms of illness you have facing? What do you think is the cause? 18. How do you know if you are not feeling well? 19. Tell me about the health services you need now. What are you doing to satisfy those needs? 20. Do you see any difference in your health status before coming to the hospital for diagnosis and after coming for diagnosis? Tell me about the difference. Health seeking behaviour 21. Where do you go or whom do you consult when you are facing a health challenge? Why that choice? 22. What makes you go to the hospital? What stops you from going? 23. Tell me about what made you go to the hospital for a diagnosis. 24. What benefit did you get from going to the hospital for a diagnosis? What challenges did you face? 25. Tell me what you do to ensure you don’t fall sick. Factors influencing drug use 26. Tell me why you still use drugs 27. What stops you from using drugs? 80 University of Ghana http://ugspace.ug.edu.gh 28. Where do you get money to buy the drugs? 81 University of Ghana http://ugspace.ug.edu.gh 3 key informant Interview guide for gate keeper in the Ghetto Introduction I am conducting a study to assess the Health Seeking Behaviours among Drug users in the Sunyani Municipality. I will be grateful if you could spend a little of your time to complete this interview with me. There are no right or wrong answers. Any information provided is private and confidential. This study is only for academic purposes. Your participation in this study is entirely voluntary. Please feel free to answer the questions below. Thank you. Participant Code……………. Date of interview……………… Demographics The following questions will be about your demographics characteristics (age, marital status, etc) 1. How old are you? 2. Sex 3. What is your ethnicity? 4. What is your marital status? 5. Do you have Children? How many children do you have? 6. What is your highest educational level? 7. What is your occupation 8. Where do you live? 9. Which religion do you belong to? Drugs being used 10. Do you still use drugs? Are people increasingly using drugs? 11. Tell me the drug(s) that are used. How often do people use it/them? 12. Why are those particular drugs used? Why do they use those drugs mentioned? 82 University of Ghana http://ugspace.ug.edu.gh 13. How long have you been using them? 14. Tell me the benefits gotten from using them. What benefits do the other drug users also get? Healthcare needs 15. Tell me how you see your health status to be currently. What about the health status of drug users? 16. What health challenges do drug users face? Which is most serious? 17. Could you tell me the symptoms of illness drug users face? What do you think is the cause? 18. How do you know if you are not feeling well? 19. Tell me about the health services drug users need now. What are you doing to satisfy those needs? Health seeking behaviour 20. Where do they go or whom do they consult when you are facing a health challenge? Why that choice? 21. What makes them go to the hospital? What stops them from going? 22. Tell me what they do to ensure they don’t fall sick. Factors influencing drug use 23. Could you tell me why they still use drugs? 24. What stops them from using drugs? 25. Where do they get money to buy the drugs? 83 University of Ghana http://ugspace.ug.edu.gh 4. key informant Interview guide for gate keeper in the Hospital Introduction I am conducting a study to assess the Health Seeking Behaviours among Drug users in the Sunyani Municipality. I will be grateful if you could spend a little of your time to complete this interview with me. There are no right or wrong answers. Any information provided is private and confidential. This study is only for academic purposes. Your participation in this study is entirely voluntary. Please feel free to answer the questions below. Thank you. Participant Code……………. Date of interview……………… Demographics The following questions will be about your demographics characteristics (age, marital status, etc) 1. How old are you? 2. Sex 3. What is your ethnicity? 4. What is your marital status? 5. How long have you been working here? 6. What is your job title? 7. Which religion do you belong to? Drugs being used 8. Do people still report with drug related issues? 9. Tell me the drug(s) they normally use. 10. Why do they use those particular drugs? 11. Tell me the benefits they get from using them. 84 University of Ghana http://ugspace.ug.edu.gh Healthcare needs 12. Tell me how you see their health status after using the drugs for sometime 13. What health challenges do they experience? Which is most serious? 14. Could you tell me the symptoms of illness they normally face? What causes that? 15. Tell me about the health services you see they need now. How do they satisfy those needs? 16. Do you record any difference in their health status before coming to the hospital for diagnosis and after coming for diagnosis? Tell me about the difference. Health seeking behaviour 17. Where do they go or whom do they consult when facing a health challenge? Why that choice? 18. What makes them come to the hospital? What stops them from coming? 19. What benefit do they get from coming to the hospital for a diagnosis? What challenges do they face? Factors influencing drug use 20. Tell me what makes people still use drugs in the municipality 21. What stops them from using drugs? 22. Where do they get money to buy the drugs? 85 University of Ghana http://ugspace.ug.edu.gh Appendix 3: Table of themes Main theme Codes under the Definition of theme Example of data located theme under theme Drugs being used Cocaine Common Drugs that For here, it is mostly the heroin are being used among cocaine that people use. marijuana the drug users in the Recently too, the tramadol tramadol municipality too they use it here… Healthcare needs Addiction, Malaria, Reported and observed The main health challenge lungs and breathing Healthcare needs of we the junkies face is complications, the drug users malaria… cardiovascular The way I feel in my body complications, poor when I don’t get some of health status, oral the drugs, it is severe than health, skin any form of illness… complications Health seeking Illness perception, The health seeking Whenever I feel sick, I see it behaviours illness identification, behaviours of the drug to be ‘turkey’… Illness treatment users. How they are …So, after using it practices, able to identify illness, (cocaine) and I still feel determinants of what they think about unwell, then I know that I treatment practices illness and where they am sick… prefer seeking I buy medicine from the healthcare. pharmacy… And a lot of people also don’t know where to go to 86 University of Ghana http://ugspace.ug.edu.gh in order to be able to stop using the drugs Social and Peers, euphoria, The social and It was through friendship economic factors stressful life events, economic factors that that I was introduced to the influencing drug Accessibility, influence drug use in cocaine… use anxiety, media the Municipality With this, it is just like some advertisement sort of feeling… If I don’t use it, I am not able to work… 87