ATTITUDES TOWARD PERSONS WHO ABUSE DRUGS IN ONE URBAN COMMUNITY ON THE ISLAND OF NEW PROVIDENCE, BAHAMAS

Objective: to explore the attitudes toward persons who abuse drugs (alcohol, marijuana, and cocaine) in one urban community on the Island of New Providence, in the Bahamas. Method: a cross-sectional survey was utilized to get the data. The sample size was 126 respondents. Results: attitudes toward persons who abuse cocaine were significantly more negative compared to attitudes toward persons who abuse marijuana and alcohol. Age and level of educational attainment were associated with more negative attitudes toward persons who abuse cocaine. Personal use of marijuana and knowing someone who abused the substance were correlated with more positive attitudes toward persons who abuse marijuana. Conclusion: attitudes toward persons who abuse drug in the Bahamas varied depending on the type of drug abused.


3/12 INTRODUCTION
Substance Use Disorders are among the most stigmatized health-related conditions affecting persons in communities globally; and despite public education efforts, have remained stable over time.According to population studies of major industrialized nations, greater social distance is desired from persons who use substances than persons with various mental and physical conditions such as Schizophrenia.][3] Much of the research on stigmatizing attitudes however, has linked Substance Use Disorders with mental illness.Hence, the underlying attitudes that characterize stigma and discrimination specific to Substance Use Disorders have not been adequately captured in the scientific literature, resulting in a knowledge gap. 1 It appears that efforts to improve the general public's understanding of addiction as a brain disease, may have added to the stigma by suggesting chronicity of the condition and a lack of control on the part of those who are affected. 4Media portrayal of persons with Substance Use Disorders as unpredictable and dangerous have also proven counter-productive to efforts at social inclusion. 5As a result, researchers saw the need to conduct more thorough analysis of the specific issues surrounding public opinions and attitudes regarding persons with Substance Use Disorders. 6o this end, a study investigated the presence of different types of stigmatizing attitudes and how stigma is expressed among various groups within society.Attitudes in the general population were compared to attitudes among categories of health professionals.It was determined that while beliefs in specific stereotypes were similar among groups, stigmatizing attitudes were greater among the general population.In addition to requiring greater social distance the public was also less optimistic regarding the potential for rehabilitation. 1Attribution beliefs on the other hand, showed greater variability among groups.
Meanwhile, in a study from Brazil, stigma was also high among family members of persons who use drugs.Respondents expressed lower opinions of drug users and indicated that they were not trustworthy. 7It was postulated that this could lead to social isolation and limit possibilities for recovery.
The recent opioid crisis in North America has sparked renewed interest in public attitudes towards this group of persons.Evidence suggests that even among persons with personal experience of use or familiarity with someone who uses, stigma is high; and the higher the stigma, the greater the support for punitive measures, as opposed to a public health approach to addressing the problem. 8his underscores the view that stigma in all its forms including, self-stigma, presents a barrier to treatment and increases social isolation. 6enerally, public attitudes were found to be more negative, and co-existed with less support for public policies that support social integration.Ambivalence regarding causality (illness or moral failing), contributed to stigmatizing attitudes.The social ramifications of use such as criminal activity and driving under the influence supports the narrative that persons who abuse drugs are dangerous and less deserving of assistance. 5n light of the available evidence there is a general consensus within the scientific community that the Public Health approach provides the best promise for effectively addressing the multifaceted problem of drug use, dependence and associated problems; particularly given the large number of underserved persons with Substance Use Disorders. 9Caution should be exercised in the application of this approach however, to ensure that emphasizes is placed on the treatability of the condition, similar to the method used to sensitize the public regarding HIV/Aids. 5lobal trends in drug use, including use of New Psycho-active Substances (NPSs), the opioid crisis in North America, (juxtaposed against the need to ensure availability of lifesaving drugs), and the popularity of marijuana use and growing support for its legalization, raises the consciousness level within society and signals the need for more research into the attitudes of individuals and groups toward persons who are struggling with drug related issues. 9roadly defined, attitude involves judgment, thought and behavior.Factors that shape the development of attitudes and their impact at the societal level are best conceptualized by the ecological theory. 10This theory provides a framework for understanding how attitudes are formed and maintained through a network of interrelationships and bi-directional influences between the individual, structures within the micro system such as the family, school, church and neighborhood and the macro systems such as culture, religion, policies and laws.The application of this theory to the understanding of attitudes toward persons with substance use disorders and their place in society will be developed throughout this paper.
Despite efforts by the major industrialized nations to study public opinions and attitudes toward persons with Substance Use Disorders, significant gaps still exist, particularly within the Caribbean and Latin American context.More specifically there has been no research that investigates the relationships between attitudes and Substances Use Disorders in the archipelagic nation of the Bahamas.
Marijuana, alcohol and cocaine were identified among the most commonly used substances in The Bahamas. 11Data from treatment facilities in the country indicate that the same substances are commonly used by the treatment-seeking population. 12Alcohol is a legal drug that is socially accepted and readily available in the Bahamian society.Marijuana, on the other hand, is a prohibited substance but the most commonly used illicit substance. 11he purpose of this study was to explore the attitudes of residents in an urban community on the Island of New Providence, toward persons with Substance Use Disorders, specifically alcohol, marijuana and cocaine.The types of attitudes of interest were positive, negative and ambivalent.Attitudes that were affirming, non-discriminating, and inclusive were identified as positive.By contrast attitudes that were discriminatory, isolationist, or stigmatizing were classified as negative.Uncertain positions were regarded as ambivalent attitudes.

METHOD
This study was a cross-sectional survey.The target population was urban young adult population of one community in the Island of New Providence, Bahamas.The sample was obtained from an urban community with a population size of 8,489 randomly selected from among the 25 Electoral Districts on the Island of New Providence.This island is home to the capital city, Nassau and 90% of the country's population of approximately 369,670. 13Nine Enumeration Districts (clusters) were randomly selected to represent that urban community -three each from the lower, middle and highincome brackets.Within these nine clusters, households were randomly selected until the target sample size set at 121, was achieved.Oversampling was required to satisfy, and gender and age group quotas, resulting in a final sample size of 126.
Due to financial and time constraints, only adults aged 18 to 65 years, able to give informed consent, were included.Houses where no one was at home, where there was no eligible respondent or consent was not obtained were skipped and the immediate next house was selected.This process continued until an eligible and willing participant was obtained.Individuals within each selected household were subsequently selected using quota sampling to ensure near equal representation of gender and age groups (18 to 29, 30 to 49 and 50 to 65).Research assistants were provided with a householder selection grid to guide the alternating selection of householders by gender and age group.If more than one householder met the eligibility criteria, a volunteer was accepted.If a house failed to produce the required gender that house was skipped.However, if a house failed to produce a participant in the required age group a substitute from any of the other age groups was accepted.

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A 15 item self-report questionnaire was specifically designed to study the multi-dimensional attitude construct in this study by adapting questions obtained from three validated instruments -the Bogardus Social Distance Scale, 14 the Drug-Related Knowledge, Attitudes and Beliefs in Ireland questionnaire 15 and the Addiction Belief Inventory (ABI) 16 and including additional questions informed by the logic of these instruments.The questionnaire was divided into three distinct sections namely: Personal Contact, Judgment and Social Support.Each section consisted of five questions.Questions in the Personal Contact section sought to measure the degree of social distance participants sought from persons who abuse drugs; the Judgment section focused on knowledge, beliefs and opinions of persons who abuse drugs; and the Social Support section ascertained participants agreement with the provision of social support for persons who abuse drugs.All these questions used 5 point Likert scales and were replicated four times, once for each drug studied: alcohol, marijuana, cocaine and crack.A score of 1 on an item indicated a positive attitude, 5 a negative attitude and 3 an ambivalent attitude.Scores were summed to obtain scale scores for each section and an Overall score for the three sections together; summed scores were equally divided to create 3-catergory attitude scales, representing the dependent variables for this study.
Independent variables were represented by the following socio demographic variables: age category (18-29, 30-49, 50-65), gender (male/female), religiosity, education, marital status (reduced to a 2-category variable because of low numbers in some of the categories), employment status experience through personal use and knowing someone who abused any of the substances studied.The lack of identifying information on any of the documents helped to reduce concerns regarding admission of illegal substance use by participants.Abuse was described in the introduction to questionnaire as "use of substance resulting in problems for the user, family members and others around them".Synonyms such as misuse or problem use were also used to explain the concept.Additionally, participants were asked if they distinguished between cocaine and its derivative, crack.If there was no distinction made, then questions related to crack were not asked.
Face and expert validation were carried out through three focus groups comprised of lecturers and students from the CAMH/CICAD 2013 Drug Research Program.Final adjustments were made to the instrument after research assistants pre-tested the instrument in the Bahamas using ten volunteer subjects to ensure that the language was culturally relevant.
The questionnaires were applied by six pairs of research assistants; each team comprised one mental health professional who conducted the interviews and one recovering addict.The interviewers were selected and trained over a period of three months by the Principal Investigator.Door-to-door interviews were conducted in pairs to ensure the safety and integrity of the process.Consent was obtained prior to the interviews and confidentiality was protected by not including participants' names on any of the documentation.
Reliability testing with Cronbach's Alpha was conducted to create an Overall attitude scales.Items were eliminated from the original 15 item inventory until reliability coefficients of at least .6 for all drugs were achieved, resulting in a 9-item scale.Tables 1,2 and 3 display the Corrected Item-Total Correlation scores and reliability coefficients for the 9 items that comprised the scales.Total scores for the scale ranged from 9 to 45.The range of scores from 9 to 20 represented a positive attitude, 21 to 33 an ambivalent attitude and 34 to 45 a negative attitude.Statistical analysis was descriptive and relationships between socio-demographic variables, type of drug abused, and attitudes were assessed using analysis of variance tests.T-tests were used because of small cell sizes for the 3-category attitude variables: paired samples t-tests were conducted to compare overall attitudes toward persons who abuse alcohol, marijuana and cocaine; independent samples T-tests to explore relationships between socio-demographic variables, (except for age), and Overall attitudes; independent samples T-tests to explore relationship between personal experience with a substance on attitudes toward persons who abuse the same substance; and Kruskal-Wallis to compare attitude means among the 3-category age variable for alcohol, marijuana and cocaine.All data analyses were performed using the statistical package SPSS®, version 20.0.

RESULTS
Socio-demographic characteristics of the sample are displayed in Table 4. Quota sampling ensured nearly equal distribution across gender and within age categories.The majority of the sample was employed, described themselves as religious, and achieved a post-secondary level of education.Single and married persons represented the largest relationship status groups.Cocaine and crack were viewed similarly by most participants.As seen in Table 5 most participants admitted to using alcohol at least once in their lifetime.Marijuana was the most commonly used of the illicit substances.The majority of participants admitted to knowing someone who abused the alcohol, marijuana, and cocaine.Mostly ambivalent attitudes were revealed toward persons who abuse alcohol (75.4%), and marijuana (69.6%)Negative attitudes were most evident for cocaine (61.9%).A low percentage of positive attitudes were indicated for marijuana (10.4%) and alcohol (4.8%) only.Since the majority of the sample did not differentiate between cocaine and crack, separate analysis was not run on that group.

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Table 6 displays variations in mean attitude scores for all independent variables studied by type of drug abused.Paired-samples t-tests, conducted to compare attitude means, across the three drugs (alcohol, marijuana and cocaine), revealed a significant difference in attitudes toward marijuana and cocaine abuse (p=.000); and alcohol and cocaine abuse (p=.000).There was no significant difference between attitudes toward persons who abuse alcohol and persons who abuse marijuana.Attitudes were significantly more negative toward persons who abuse cocaine compared to alcohol or marijuana.
Age and level of educational attainment were the only socio-demographic variables found to be associated with attitudes.Independent samples T-tests revealed significant difference between secondary level education and post-secondary level of education.Participants with a post-secondary education had more negative Overall attitudes toward persons who abuse cocaine than those without a post-secondary level education (p=.054).No significant relationship was evident for level of education and attitude toward persons who abuse alcohol or marijuana.
Kruskal-Wallis test also found significant difference in attitudes toward persons who abuse cocaine across age groups (p=.02) with the older age group having the more positive attitudes (Mean Rank=53.85) and the younger age group being more negative (Mean Rank=75.25).There was no significant relationship between age and attitudes toward persons who abuse alcohol or marijuana abuse.
Use of marijuana by participants was associated with more positive attitudes toward persons who abused marijuana compared to participants who did not admit to marijuana use (p<.0005).Findings were insignificant for alcohol and tests were not conducted for cocaine since less than 2% of the sample admitted to cocaine use.Knowing someone who abused marijuana was also related to more positive attitudes toward persons who abused marijuana (p<.0005).Knowing someone who abused alcohol and cocaine had no significant effect on attitudes toward persons who abused the same substance.

DISCUSSION
This study explored the attitudes of the adult population in the Bahamas toward persons who abuse alcohol, marijuana and cocaine.Attitudes were generally ambivalent toward persons who abuse alcohol and marijuana, suggesting that respondents held less rigid and stereotypical views regarding persons who abuse these substances.This finding was not surprising given the ease of access and social acceptability of both substances in the Bahamian society. 11It is conceivable therefore, that this ambivalence signals an opportunity for education and attitude change.
On the other hand, study participants held definitively more negative attitudes toward persons who abuse cocaine, indicating a stronger moralistic position and desire for greater social distance from this group of persons.Younger participants (ages 18 to 29), were even more discriminating and judgmental toward persons affected by cocaine abuse than their older counterparts.Participants with a tertiary level of education also had more negative attitudes.This is best understood in context, considering Bahamians have witnessed firsthand the adverse social, economic and legal ramifications of cocaine abuse and dependence over the past thirty years. 11In addition, beliefs in dangerousness 10/12 exacerbated by well meaning, though seemingly misguided, public education messages about the dangers of drug use and links to criminal activity may have further contributed to the stigma associated with cocaine use. 12ot surprisingly, personal use of marijuana and knowing persons who abuse the substance had a positive effect on attitudes towards people who abuse marijuana.8] No such relationship between attitudes and personal experience with alcohol or cocaine use was noted however; as the public health, psycho-social, and economic problems associated with the abuse of these substances within the Bahamian society has been well documented and publicized over the years. 11s a critical part of the social ecosystem individual members of society are instrumental in the process of social change.Therefore, understanding their attitudes as expressed through cognitive, affective and behavioral manifestations can serve as a baseline for the development and implementation of a public education strategy focused on shared responsibility and a broad bio-ethical approach to understanding the multi-faceted problem of substance use and related disorders within the social context.From this research, however, have limited generalizability to the rest of the Bahamas, because of the small sample size.Additionally, the percentage of respondents who admitted to illicit substance use may not be a true reflection, given the challenges associated with such an admission, particularly in a face to face interview.

CONCLUSION
Finding from this study suggest that attitudes of urban residents in The Bahamas toward persons who abuse drugs vary depending on the type of drug abused.Persons were more likely to express ambivalence in response to alcohol and marijuana abuse; whereas, cocaine abuse elicited more negative responses.Residents desired greater social distance from persons who abused cocaine and were more likely to make harsher moral judgements.This was most evident among the younger age group and declined with age; level of education was also associated with more negative attitudes toward this group.
Furthermore, personal experience with marijuana use had a positive effect on attitudes toward persons who abuse marijuana, consistent with a global shift in attitudes toward the use of this substance.These variations in attitudes may have implications for the application of a public health approach to addressing the problems associated with Substance Use and Related Disorders in the country.
Further exploration of the interaction between individual factors and the larger social structures within the society is needed to guide the development of policies and programs aimed at tackling stigma and discrimination of persons with Substance Use Disorders, regardless of the substance.
Baseline data from this study can be instructive in the formulation of future studies to investigate the role of social factors in the development of attitudes toward persons who abuse drugs.

Table 1 -
Statistical Reliability Analysis for Overall Alcohol Attitude Scale, Bahamas, 2013

Table 2 -
Statistical Reliability Analysis for Overall Marijuana Attitude Scale, Bahamas, 2013

Table 3 -
Statistical Reliability Analysis for Overall Cocaine Attitude Scale, Bahamas, 2013

Table 5 -
Percentage of study participants' who used substances and knew someone who abused substances.Bahamas, 2013

Table 6 -
Mean attitude scores for Socio-demographic variables by drug type.Bahamas, 2013