Alcohol and Drug Abuse Research Unit

Report to Parliament 2008: Alcohol and Drug Abuse Research Unit
Selected Research Highlights 2007-8

Access to substance abuse treatment for historically disadvantaged communities in Cape
A mixed methods design was used that comprised a case-control study and qualitative in-depth interviews. For the case-control study, data were gathered from 434 cases that had accessed treatment and 555 controls who had alcohol or drug problems but had not accessed services.  Equal proportions of women and men were selected for both the case and control conditions. To be eligible for participation in the study, cases and controls had to be over the age of 18, earn less than R2000 a month, and have a diagnosis of substance abuse and/or dependence. Cases and controls were selected from twelve historically disadvantaged communities in the Cape Town metropole.  Traditionally black/African and Coloured communities were equally represented.  The qualitative phase explored contextual influences on alcohol and drug treatment uptake for people from these communities. This study found inequities in the use of alcohol and drug treatment services. The primary determinant of treatment uptake was not need, but rather factors such as affordability, geographic accessibility and awareness barriers. Compared to men, women from these communities did not have equal access to treatment services. Vertical inequities in access to treatment were also present: people with relatively severe alcohol and other drug problems experienced more difficulties in accessing services than those with less severe problems.  Contextual influences that appear to underpin these inequities were identified. These included: difficulties in service planning for alcohol and drug treatment due to infrastructural issues, (ii) limited allocation of resources to alcohol and drug treatment which restricted the availability of affordable services and the capacity of established services to meet the demand for services, (iii) concerns about service quality, (iv) and the impoverished and fractured nature of these communities. These findings highlight the need for further transformation of the social welfare system responsible for treatment delivery. Specific, practical recommendations for how to improve access to treatment for these communities are made. 

Bar-based HIV intervention
The formative research was conducted in a city and township site in Gauteng province. It sought to ascertain (a) the nature and extent of alcohol consumption and sexual risk behaviour among patrons of six drinking venues in the two sites, and (b) the likely feasibility, acceptability and effectiveness of various intervention approaches to reduce levels of alcohol consumption and sexual risk behaviours among patrons who visit drinking venues.

A survey of a random sample of 314 patrons in six drinking venues indicated that most patrons were male (75%), unmarried (although they had steady partners), of a relatively high level of education, and employed (2/3), while just over ¼ were students. Binge drinking (consumption of 5 or more drinks per occasion) was very common, and results on the Alcohol Use Disorders Inventory Test revealed that many patrons engaged in hazardous/risky drinking. The patrons also had high reported levels of engagement in risky sexual behaviours, including engagement in unprotected sex, sex under the influence of alcohol, and sex with concurrent partners including commercial, casual and one-off partners. Consensual sexual interactions were perceived to be initiated and/or to take place at drinking venues. About one tenth of the participants reported having possible STI symptoms, and the reported rate of testing for HIV infection was approximately 50%.

Qualitative assessments entailed conducting focus group discussions among patrons and servers of drinking venues and in-depth interviews among key informants and owners/managers of venues. Based on the survey, a systematic review of literature and the participants’ qualitative assessments of the strengths and weaknesses of various approaches to reduce harmful alcohol use and sexual risk behaviours among patrons within drinking venues, we are devising an intervention programme that will be implemented and undergo a process and outcome evaluation. The intervention will consist of: (a) on-site trained servers who will encouraging responsible drinking and sexual risk reduction; (b) trained bar patrons who will serve as peer educators/leaders; (c) the provision of education, counselling and referrals by professionals to outside counselling and treatment services; (d) the display of posters with prevention messages; and (e) the consistent distribution of affordable condoms at drinking venues.

Audit of substance abuse prevention programmes in Cape Town
An audit of primary prevention programmes was conducted to increase knowledge on the types of primary prevention programmes offered, skills levels of prevention workers, provider information and evaluation methods, and to use this information to inform current primary prevention service planning and delivery at local, provincial and national level. A cross-sectional survey of primary prevention programmes was conducted. The sample consisted of 47 organizations in Cape Town that provide primary prevention programmes. Data for the audit were collected using a structured questionnaire. The response rate for the questionnaire was 74%.

The findings from the study indicated that due to limited funding for prevention activities, NPOs were most likely to be engaged in primary prevention activities as a secondary focus of their work. Adolescents are the most common target. The majority of primary prevention programmes do not target individuals with a higher number of developmental and social risk factors, but rather focus on adolescents in general. This suggests that the indicating an uneven distribution of selective and universal prevention programmes.

A breakdown of the proportion of programmes surveyed that focus on different target populations is given below:

Of major concern is that most primary prevention programmes appear to be implemented in the absence of evidence on their effectiveness and are mostly implemented on an ad hoc basis. The majority of primary prevention programmes are once off sessions, with only 60% of organizations conducting follow-up sessions. The respondent organisations displayed a poor understanding of evaluation, with few providers understanding the difference between outcome and process evaluations. Reports such as annual and quarterly reports were thought of as evaluation reports.

There is a need for a systematic review of what works in the context of substance abuse prevention among South African populations as well as the development of an effective regulatory regime in the form of minimum norms and standards for primary prevention activities. To ensure that substance abuse prevention meets international best practice standards, publicly-funded primary prevention training courses should be developed for organisations doing prevention work. This should include training in how to conduct routine evaluations.

Foetal Alcohol Syndrome
The household survey conducted in the Tshwane and Western Cape sites revealed stark differences between women of child-bearing age in the rural and urban site. The urban women were significantly more likely to be unemployed, while also being more highly educated than their rural counterparts. The risk of having an alcohol-exposed pregnancy was significantly higher among the rural women than the urban women. The significant and independent predictors of being in the “at risk” group for the urban women were (a) “ethnicity” (being “white” or “coloured” as opposed to “black/African”; (b) current smoking; and (c) alcohol use onset as a minor. For the rural women the significant predictors were low education; current smoking; alcohol use onset as a minor; lack of knowledge about FAS; and parity (i.e. the number of children given birth to). The results of the study suggest an urgent need for location-specific programmes to prevent women’s risk of having an alcohol-exposed pregnancy. Universal, selective and targeted intervention approaches are required to reduce levels of risk of alcohol-exposed pregnancies among women in South Africa.

Substance abuse treatment centre audit
A cross-sectional audit of substance abuse treatment facilities in Gauteng and KwaZulu-Natal (KZN) was conducted in 2006/7. Findings show that despite a high demand for substance abuse treatment services, treatment facilities are under-utilised in these provinces. The range of treatment services provided by substance abuse treatment facilities in Gauteng and KZN is also limited, with few facilities providing comprehensive services that integrate medical and mental health services with addiction services. Findings suggest that Black/African and female substance abusers remain under-represented in treatment facilities. In terms of activities that target barriers to treatment entry for historically underserved population groups; while a significant proportion of facilities perform outreach activities aimed at improving awareness of treatment options, there is still room for improvement. As few facilities employ dedicated outreach workers, the frequency with which outreach is conducted is highly questionable. In terms of logistic and affordability barriers, while many facilities report providing financial assistance for the direct costs of treatment in terms of reduced fees, there are still relatively few free treatment slots available to indigent clients. This raises a concern about the availability of affordable treatment options to poorer communities. In addition, few facilities address the indirect costs associated with treatment entry, such as the costs of transport. Several recommendations are made to address cost barriers. These include increasing the provision of state-funded outpatient services and shifting from facility-based outpatient service provision to the use of mobile clinics located in disadvantaged, high-need areas. In terms of linguistic barriers to treatment entry, while several facilities report employing multilingual staff, a much smaller proportion of facilities employ African language-speaking therapists. This continues to be a barrier to treatment entry for Black/African persons. Recommendations for addressing this include training more African-language speaking health and social work professionals. Findings point to the need for routine, systematic client monitoring systems as well as the need for treatment programmes to be evaluated. As part of the monitoring of the extent to which these services have transformed to address historical inequities in service provision, a national treatment audit should be conducted on a regular basis.

Street Children: Risk and Protective Factors
The overall aims of the study are to investigate: (a) the nature of the risky (maladaptive) and opportunity (adaptive) outcomes experienced by street children in Pretoria; and (b) the predictors of risky and opportunity outcomes of street children in Pretoria. We used purposive sampling and conducted in-depth interviews with ten key informants, and five focus group discussions among children who lived and/or worked on the streets or in shelters in Pretoria. The results indicated that despite their reasons for leaving home, perceptions that street life would be appreciably superior to circumstances at home were reported to be unfounded by many children and key informants. The following themes emerged as key risk outcomes associated with life on the streets: limited access to basic services, education and health care; vulnerability (and lack of protection); victimisation; stigmatisation; and engagement in problem and criminal behaviours as coping strategies. More positive outcomes were perceived to pertain to those with strong social and emotional support (e.g. from peers, outreach workers, and community members), and a strong sense of acceptance and optimism about the future. A common sentiment was of the importance of shelter contact for short-term outcomes and education for longer-term positive outcomes.

Preliminary analyses were conducted of data obtained from 71 children who lived and/or worked on the streets or lived in shelters, to compare predictors of anti-social (violence and drug use) and pro-social behaviours (pro-social outcomes and sense of belonging). The results indicated that both individual (e.g. self-esteem, spirituality) and peer (e.g. risk, support) factors were more strongly associated with anti-social behaviours than with pro-social behaviours. A few parental factors (parental contact, monitoring and cohesion) were associated with both anti-social and pro-social behaviours. School variables (e.g. atmosphere) were associated with both anti-social and pro-social behaviours. The results suggest an urgent need for programmes to increase the accessibility of supportive school, peer and family environments for children who live and/or work on the streets.  In addition, programmes are required to assist street children to transition into shelters and/or back to their homes of origin, where appropriate.