Exploring treatment barriers on the use of crystal methamphetamine among young people in Harare, Zimbabwe

ABSTRACT

Background

Substance misuse among young people is one of the most public concerns in global health. This study set out to explore treatment barriers and abstinence paradigm among young people.

Methodology

This study utilized an explorative qualitative approach. A semi-structured interview guide was used to collect data from 30 participants. The data was thematically analyzed.

Results

The study found that the barriers to treatment among the young people included fear of being incarcerated, poor drug awareness, stigmatization, inhibiting financial costs for treatment, and conflating drug use with personal freedom.

Conclusion

There is a need to improve drug awareness and treatment among young people in low- and middle-income countries (LMICs).

KEYWORDS:

• Drug use
• Young people
• Stigma
• Methaphetamine
• Treatment

Background

Among a myriad of public health concerns, harmful substance use has gradually emerged as one of the most topical issues in global health (Kristjansson et al., 2020). Substance misuse significantly contributes to the global disease burden and mortality rate. The use of crystal methamphetamine can cause a wide range of medical and psychological conditions. Crystal methamphetamine gradually kills the brain’s dopamine cells eventually leading to symptoms of psychosis, paranoia, and impaired thinking-related skills like problem solving and memory (Abdul Muneer et al. 2011). Meth users can also have high cholesterol and an elevated risk of heart disease (Yu et al., 2003). Meth may weaken the immune system and catalyze the deterioration of conditions such as HIV and Hepatitis C Virus (HCV) (Yeo et al., 2007).

Treatment utilization is low among people using methamphetamine, while the exact nature of treatment barriers remains relatively unknown (Kenny et al., 2011). While there has been considerable research on illicit drug use treatment barriers, there is a paucity of research specific to methamphetamine treatment (Kenny et al., 2011). Research indicates a growing need for methamphetamine-appropriate treatment. Also, with the growing use of the drug injection method, there are growing concerns for accelerated transmission of HIV infections and other blood-borne diseases such as HCV.

Research has shown that one of the reasons people using methamphetamine do not seek treatment is that they do not consider themselves as “hard drug” users (Kenny et al., 2011). Privacy concerns have also been documented as hampering treatment utilization among individuals living with substance use disorders (Ball et al., 2006). Due to the stigma attached to substance use issues, there is some measure of sensitivity related to its prevention and treatment processes: low treatment engagement rates and high treatment dropouts are common where privacy surrounding the treatment process is compromised. Ball et al. (2006) cites poor motivation as another reason why healthcare service utilization is low among people using substances. The low motivation to seek treatment is sometimes as a result of the need to avoid inquiry and monitoring of their drug use.

Pasche and Myers (2012), argue that South Africa and other low-to-middle-income countries such as Zimbabwe have relatively limited capacity to respond to the methamphetamine epidemic due to inadequate health-care facilities, under-resourced treatment centers, and inadequate specialist health-care personnel. The lack of specialist methamphetamine clinics and treatment services oriented toward people using methamphetamine have also been cited as major concerns that slow down treatment access and utilization.

Although abstinence outcomes remain the preferred goal of substance use interventions, the reality is that abstinence outcomes are a high standard to achieve and not always easy to attain. Patients reporting higher perceived coercion upon admission for substance use treatment are more likely to leave treatment soon afterward. On the contrary, patients reporting greater autonomy in entering treatment (associated with harm reduction principles) have been observed to stay on treatment and achieve better outcomes. Apart from the perceived ineffectiveness of abstinence-centered approaches, ethical issues have been raised relating to the use of coercion to induce treatment initiation.

Zimbabwe has been grappling with rampant drug use, with methamphetamine (a form of the drug amphetamine) being one of the most popular drugs of choice. Other countries in the region, such as South Africa, are also facing a growing methamphetamine epidemic in addition to the opioid use crisis (mainly heroin). Zimbabwe has a largely youthful unemployed population owing to the failed economy and political system (Gukurume, 2018).

Crystal methamphetamine, is a type of stimulant (ATS) that produces multiple neurobiological effects on the nervous system with effects that are highly reinforcing through activation of the reward system of the brain, which causes a rapid sense of euphoria, but potentially leads to use and dependence. It is an illicit white crystalline drug that people take orally, inhale, smoke, or inject using needles and has several street names such as crystal methamphetamine, crank, speed, tik, and mutoriro in the vernacular Shona language widely spoken in Zimbabwe (Mukwenha et al., 2021). Many young people have therefore turned to drugs to find solace and entertainment leading to a myriad of social problems among the youth and early incarcerations within the criminal justice system (Mukwenha et al., 2021). Considering the above assertion, this study set out to explore treatment barriers among young people in Zimbabwe.

Research design

The study utilized an explorative qualitative approach (EQA) conducted with young people who were using crystal methamphetamine. EQA is important for understanding the problem rather than offering the final solution to the problem (Gericke et al., 2018). EQA just like any other qualitative research relies on understanding the lived experiences of the research participants.

Data collection

Using an interview guide, in-depth face-to-face semi-structured interviews were conducted with current young adults living with methamphetamine use disorders. The participants were purposively sampled from the young adult population (18–30 years) on treatment for methamphetamine use disorders in various registered in-patient and out-patient facilities in Harare. The semi-structured interviews in this study used a combined sample size of 30 participants. After interviewing the 30 participants, it was clear that there were no more new themes emerging. Table 1 shows the semi-structured questions that were utilized for the study.

Table 1. Semi-structured interview schedule questions.

Interview Schedule
1 Briefly explain what you think prevents most young people using meth from seeking treatment
2 May you comment on the level of substance use awareness in the community
3 What is the general attitude of the community towards people who use meth and does it bother you
4 What do you know about harm reduction and abstinence in the context of substance use treatment
5 What are your perception of the effectiveness of harm reduction and abstinence intervention strategies
6 By referring to the different substance use methods that you know, explain your views whether these methods are effective or not.
7 To what extend was his statement true to your own situation before you decided to seek help.
8 To what extend was the financial resources (cost) an important factor in you determining whether to seek treatment or not explain
9 The treatment facilities for substance use are very few and sometimes these facilities do not have enough health care workers. Make a brief comment about this statement
10 What is your comment on the rule of cultural beliefs in relation to seeking help among people using substances
11 What are your own recommendations to improve substance use health care services

Piloting

Five respondents participated in a pre-testing exercise in order to determine if the interview guide needed any modification. All five respondents reported that the questions were clear and concise, and the researchers proceeded to conduct the interviews with the 30 respondents.

Data analysis

The interviews were audio-recorded and transcribed verbatim. Using Braun and Clarke’s (2006) steps of thematic analysis to code responses and develop recurring themes, data was coded in order to identify the themes and sub-themes. The six steps included familiarizing with data, assigning preliminary codes, searching for patterns or themes, reviewing themes, naming the themes, and producing a report of what was taken as the final findings of the study.

Ethics

The research study was approved by the Institutional Review Board (IRB) of the Medical Research Council of Zimbabwe, Department of Psychology. Each participant was asked to sign an informed consent form before they participated in the research. The researchers were explicit regarding the limitations of confidentiality, especially when a third party in the form of a certified service provider assisting the program or the legal system may need to be involved. All data, including paper documents, such as consent forms, and data on transportable media, such as flash memory devices and CDs, were stored in a locked file cabinet.

Results

The study found that the barriers to treatment among the young people included fear of being incarcerated, poor drug awareness, stigmatization, inhibiting financial costs for treatment, and conflating drug use with personal freedom.

Fear of being incarcerated

The research participants reported fear of being arrested by the police as one of the reasons why they do not seek treatment. They have a belief that drug treatment centers are connected to the criminal justice system.

You know what, many of us young people fear getting arrested because taking drugs for recreational purposes is illegal in this country hence, I cannot walk to a treatment center to report myself to the police. (An 18-year-old man)

Poor drug awareness

The research participants reported that although there was information to raise drug awareness most of the young people who used drugs were not privy to this information.

Yes, there is information about drug awareness out there, but the problem is that how is it being given to us as young people … … . They expect us to read posters or sit down for training and awareness campaigns honestly, we do not have time for all this hence our knowledge about drug is very low (18-year-old young person).

Stigmatization

The research participants reported that stigma from communities was one of the reasons why young people were not willing to seek treatment. They believed that many communities saw young people who peddle and use drugs as thieves and societal renegades.

Honestly how can I go and seek treatment when you hear everyone in the community labeling young people who sell and use drugs as thieves and mischievous … … … … They have already given you a tag why going for treatment to confirm that I am a thief … … . Honestly, this has to change to help us access treatment (19-year-old young person).

Inhibiting financial costs for treatment

The research participants reported that drug use treatment was expensive and could not afford the inhibiting fees. They further reported that they were not employed, hence it was difficult to get enough money to pay for treatment, which is mostly run by private organizations charging colossal treatment fees.

Even if I wanted to get treatment where will I get the money to pay for the treatment … … … Remember all the treatment centers are run as private entities hence they charge large sums of money to get treatment … … . Most of us young people have never worked in our life I just cannot do it. (19-year-old young person).

Poor support of harm reduction and abstinence strategy

The research participants reported the weakness of the harm reduction and abstinence strategy in that meth, a drug mostly used by young people in Zimbabwe, is highly addictive and readily available in the street markets at an incredibly low and affordable price.

I think that harm reduction and abstinence is not effective because meth is highly addictive and readily available in the streets at a very low price … … … I think there is need to be other methods or systems of treatment to help the harm reduction and abstinent strategies to work (22-year-old young person).

Present bias impact (use of present circumstance to justify continuous drug use)

The research participants used their present circumstance to justify continuous drug use (present bias), thereby rendering the drug reduction treatment strategies ineffective. They viewed themselves as people who had no problems with drugs as it was just a pass time hobby for people who had nothing to do.

What help our getting as young people is to improve our life … … . It is better to provide us with money to buy drugs and get high rather than roaming the streets and getting stressed with life problems that no one is willing to help you (22-year-old young person).

Conflating drug use with personal freedom

The research participants reported that drug use was a personal choice and right. They felt that no one should have the right to question them about it because it is their choice and right. This also extended into treatment where they felt that treatment is again a personal choice and therefore no one should coerce or tell them to take up treatment.

If a person has money for drug abusing, he should do that but if he or she needs assistance he or she should be assisted … … … A person should not be restrained from drug use because it’s his choice … … … This is all about our personal freedom (21-year-old young person).

Discussion

In many countries across the world, drug control in communities is mostly done through heavy-handed policing (Putzel, 2020). On many occasions, this has resulted in many people taking drugs to avoid treatment and only come to treatment through the criminal justice system. Furthermore, in many LMICs people resort to drugs due to different reasons, some of which involve unemployment (Achdut & Refaeli, 2020). In the study, the research participants reported that fear of being arrested by the police was one of the reasons why they do not seek treatment. They have a belief that drug treatment centers are connected to the criminal justice system. It is therefore important that there is a clear policing strategy that does not deter people from seeking drug treatment. The space occupied by police among people using drugs should be swapped for health promotion and drug awareness campaigns using community-based strategies

When undertaking health promotion in communities it is particularly important that the affected social group is targeted using information and language they understand (Dickerson et al., 2020). This will enable to raise awareness to both communities and people using drugs. Use of complicated health awareness campaigns may result in spending copious amounts of money without any benefit to the community (Alcaraz et al., 2020). The research participants reported that although there was information to raise drug awareness, most of the young people who used drugs were not privy to this information. It is therefore important that when health awareness programs are being planned they should be designed to target the affected social group using language and media they understand.

Stigmatization is one of the key factors why people can disengage or not engage with treatment services (Wagstaff et al., 2018). This phenomenon is not new as was learnt from HIV where people were deterred to use treatment services owing to high stigma in communities (Nyashanu, 2017). In this study, the research participants reported that stigma from communities was one of the reasons why young people were not willing to seek treatment. It is therefore important to educate and raise awareness in communities to reduce and prevent stigma toward people who use drugs. Instead, communities should be turned into pillars of support for people seeking drug treatment based on the African community philosophy of “Ubuntu” meaning I am because we are (Nyashanu, 2017).

In many LMICs, effective treatment services are privatized, while the available services run by the government have no resources to meet the demands of the population (Nyashanu et al., 2022). In the study, the research participants reported that drug use treatment was expensive and could not afford the inhibiting fees. It is therefore important that the central government through the ministry of health invest more money into developing and equipping drug treatment services.

Different people sometimes use the concept of the free world to justify their behavior, which at times can be a hindrance of receptiveness to health promotion messages. In most cases, self-freedom has been conflated with the right to some of the things that may be detrimental to the health and well-being of the community and the individuals involved (Trakman & Gatien, 2016). In this study, the research participants reported that drug use was a personal choice and a right. They felt that no one should have the right to question them about it because it is their choice and right. This also extended into treatment where they felt that treatment is again a personal choice and therefore no one should coerce or tell them to accept treatment. There is a need to open dialogue and training with young people and communities on their responsibility to the health and wellbeing of others around them. More importantly, during the training in question, there is a need to unpack personal freedom versus responsible citizenship, where attendees are allowed to reflect on the concept of freedom in relation to their ethical and community responsibilities.

Implication for practice

There is a need for professionals working in drug awareness and treatment to be supported with modern equipment and training in enabling them to engage with communities and young people affected by drugs. Furthermore, there is a need to train more health personnel at different levels and make sure that all health facilities are staffed with qualified personnel who can attend to people presenting with drugs problem.

Limitations of the study

This study was carried out in Harare, which is the capital city of Zimbabwe. However, in future research, encompassing other cities and regions across the country may enable fair comparison of crystal methamphetamine drug use situation in different parts of the country. The research utilized a qualitative approach, and future research should consider using a mixed method so that the issues can be explored from different epistemological and ontological positions.

Concluding comments

LMICs are affected by an array of health problems ranging from weak health systems to shortage of equipment and qualified personnel. This makes it difficult for the health systems to support effective drug management and treatment, leading to massive use of drugs by communities. There is need for developed countries to invest more through the United Nations to help develop capacity building and prevent over use of drugs by young people.

Acknowledgments

Our sincere thanks go to all professionals in the city of Harare, who participated in this research study. Our profound thanks go to all the young people who took part in this important study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.