RESIDENTS’ ATTITUDES TOWARD THOSE WHO MISUSE DRUGS ON THREE ATTITUDINAL SCALES

Canada. ABSTRACT Objective: to examine patterns in attitudes toward drug users among residents in a community of Kingston, Jamaica. Method: cross-sectional study; sample size was 121 residents. Results: alcohol and marijuana showed a strong positive relationship on the personal contact attitudinal scale with r (119)=.53, p<.01. Respondents’ attitudes on the judgement scale for crack and cocaine were the strongest among all the drugs with r (119)=.84, p<.01, reflective of a very strong positive relationship. Equally important too, respondents’ attitudes on the social support scale toward those who misuse crack and cocaine were very strongly correlated with r (119)=.88, p<.01. Residents displayed positive attitudes toward those who misuse alcohol and marijuana. Conclusion: the majority of respondents were ambivalent toward those who misuse cocaine and crack. Negative attitudes were highest among residents toward those who misuse cocaine. This study found that the differences in mean between males and females attitudes on the personal contact scale for alcohol and marijuana were statistically significant at 0.05 level. Our findings may be used to inform further research and ultimately lead to policy Correlation is significant at the 0.01 level (2-tailed).


INTRODUCTION
Global estimates as at 2017 have shown that five percent or 250 million people aged  have used an illegal drug at least once in 2015. 1 Substance misuse among the general population is a public health issue for many countries. The International Narcotics Control Strategy Report estimated the prevalence of cocaine use in Jamaica at less than 0.1% and that marijuana was the most used drug with 15% of the population using it at least once in 2016. 2 Non-communicable diseases rank among the leading cause of death globally accounting for 38 million deaths. Of these, 28 million deaths due to non-communicable diseases occur in low and middle-income countries. 3 In accordance with this global trend, non-communicable diseases (including cardio-vascular conditions and hypertension) and lifestyle practices, especially tobacco consumption and substance misuse, are the main causes of mortality and morbidity in Jamaica. A 2013 National School Survey on substance use among youths found that the most likely substances to be misused in Jamaica were alcohol followed by tobacco then marijuana. This survey had a sample size of 3,365 respondents. 4 Studies on attitudes of varying professional groups toward drug misusers are fairly widespread. Negative attitudes toward those who misuse drugs are common among the general population. 5 A qualitative study found that people who misuse drugs were perceived by the public as dangerous, difficult to speak with and unpredictable. Further, persons having personal experience using drugs were blamed for their health problems resulting from drug misuse because they were often viewed as self-inflicting and possessing evidence of little or no control. The perception of dangerousness and unpredictability contributes to negative attitudes among the health care professionals. Health care professionals may feel that they are unable to help individuals with problematic use of drugs. This uncertainty that they feel is sometimes compounded by the relapsing nature of recovery for those who misuse drugs. Health care professionals may also have the same negative attitude towards those who misuse drugs as does the general public and this attitude may influence how these professionals respond to patients who misuse drugs. 6 A study explored the attitudes among 144 randomly selected psychiatrists toward those who misuse drugs. This study was conducted in the United Kingdom and data was collected through a questionnaire with questions from a case history vignette. The vignette used was varied by gender and one mentioned a history of alcoholism while the other described the case with no mention of alcoholism. The researchers found that cases with the diagnosis of alcohol dependence were judged not likely to finish the course of treatment or to comply. They were also judged as unlikely to get sympathy, would not be liked in the clinic and would annoy the doctor. 7 In March 2016, the Scottish Government commissioned a study to determine public attitudes in Scotland toward individuals with a history of drug dependence and those who are in recovery. This was a baseline study with a sample size of 1,089. It showed that a significant proportion of the population felt that drug misusers had a responsibility for their own situation. Further, public attitude showed that it was within drug misusers own power to improve their problem and that lack of discipline and will power were the main causes of their drug dependence. Notwithstanding, the majority of respondents expressed sympathy and understanding toward people with drug-related problems. These findings were used by the Scottish government to inform effective responses to stigma toward persons with drug dependence. 8 Nevertheless, whereas many studies have investigated the attitude of professional groups toward substance users, few studies have examined residents' attitude toward those who misuse alcohol, marijuana, cocaine and crack. Public attitudes toward those who misuse drugs are important because rehabilitation and reintegration of these persons into mainstream society requires both 4/11 positive and accepting societal attitudes. Further, public attitudes on drug issues are critical because the success of drug-related policies depend, to a large extent, on the support of the constituents whom policy makers have to satisfy.
The purpose of the current study is to examine patterns in attitude toward drug misusers among residents in a community in Jamaica. We determine the attitude of residents toward those who misuse drugs by type of drug on an attitudinal scale.

METHOD
This study used a cross-sectional design to examine residents' attitudes toward those who misuse drugs. The questionnaire design, sample selection, data collection and analytical methods are discussed below. A number of attitudinal themes were developed to meet the study's objectives. A list of questions emerged from the following themes: Attitudes toward those who misuse alcohol, marijuana, cocaine and crack on a personal contact scale; Attitudes toward those who misuse alcohol, marijuana, cocaine and crack on a judgement scale; Attitudes toward those who misuse alcohol, marijuana, cocaine and crack on a social support scale.
Questions from these themes comprised the 70-item Multidimensional Attitude Inventory (MAI) instrument. Items on the MAI were modified from pre-existing scales, such as the Bogardus Social Distance Scale, 9 the Drug-related Knowledge, Attitudes and Beliefs in Ireland Questionnaire 10 and the Addiction Belief Inventory. 11 Items 1 and 3 from the Bogardus Social Distance Scale were modified on the MAI as questions 7,11,22,26,37,41, 53 and 57. Items 7,22, 37 and 53 ask repondents if they would hire someone who misuse drugs to work for them and items 11,26, 41 and 57 ask repondents if they would marry someone who misuses drugs. Modification to the original Borgardus Social Distance Scaled items became important because this study aims to measure components of attitude that residents have about establishing personal contact with those who misuse drugs.
Items from the Drug-related Knowledge, Attitudes and Beliefs in Ireland Questionnaire were also modified to form items on the MAI. Item 10 from the Ireland questionnaire was modified to form questions 8,23, 38 and 54 on the MAI. These questions ask respondents if they would be afraid to be around someone who misuses drugs.
Item 8 from the Addiction Belief Inventory was modified to become questions 12,27, 42 and 58 on the MAI. These questions ask if respondents think a person who misuses drugs has an illlness.
Questions 9,24,39, 55 10,25,40, 56 15,30,45,61,17,32,47,63,21,36, 51 and 67 were developed and included with the modified items on the MAI. Questions 9,24, 39 and 55 ask if respondents felt ashamed if others knew that a family member misused drugs. Questions 10,25, 40 and 56 ask if respondents would allow a person who misused drugs to baby-sit a child that is known to them. Questions 15,30, 45 and 61 ask respondents if they think that a person who misused drugs is as important as anyone else. Questions 17,32, 47 and 63 ask repondents if they think that a person who misuses drugs get enough access to social services. Questions 21,36, 51 and 67 ask repondents if they think that family support is important in caring for a person who misuses drugs.
A measure of lifetime prevalence of drugs, that is, whether respondents have ever used drugs, was included in the MAI. Respondents were also asked whether they have ever known anyone who misused drugs. These were questions 68 and 69. Variables concerning personal experience with drugs including lifetime usage and knowing someone who misused drugs were included because previous studies have found that an individual's own usage contributes to his or her attitude toward substance misuse.

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Questions 1 to 6 comprised sociodemographic questions on gender, age, employment status, religiosity, relationship status and education. Age was divided into three classes, where age-related differences in attitude toward those who misuse drugs are expected to occur. Education was represented at four levels: non-formal (experiential, traditional, cultural or apprenticeships), primary only, secondary only, and beyond secondary (training beyond secondary level).
Three expert focus groups conducted face and expert validation on the instrument. The instrument was pretested by the CICAD 2013 research team. A Cronbach Alpha test was also conducted on the instrument to determine the internal consistency among the personal contact, judgement and social support scales.
The target population was general urban residents in Kingston, Jamaica. The sample was selected from a community of St Andrew Eastern, which borders the University of the West Indies, Mona Campus.
The community was systematically selected from Jamaica's census data based on population size of between 5,000-10,000 residents and classified as an urban area. Every 5th home was selected. Individuals, both males and females were included by randomly selecting one male then one female in alternating households throughout the community. Inclusion criteria only considered individuals between the ages 18 and 65. People over 65 years old were excluded because we were interested in establishing the attitude of residents who were not at retirement age. Persons beyond 65 years old would be within the formal retirement age and hence were an excluded cohort for this study. People unable to provide informed consent or unwilling to participate were excluded. We conducted an oversampling technique to assure equal representation of male and female respondents by age category. The age categories were the following, 18-29; 30-49 and 50-65. The equal distribution of age and sex was to prevent a sample that was disproportionate in a manner that might skew the attitudinal responses obtained from this study. The total sample selected was 157.
Data was collected using face-to-face interviews at residents' homes and executed by trained interviewers. The interviewers explained the study to the residents, including the consent form, the purpose of the study and the topics it will address. Once the resident agreed to participate, the interviewer signed a copy of the consent form and it was given to the respondent. Responses were recorded on a hard copy of the questionnaire. Interviews were conducted in the month of January 2015 between the hours of 9 am to 5 pm. To maintain privacy and confidential, residents were not identified by name on the questionnaire and completed questionnaires were stored separately from the consent forms in a locked filing cabinet in the principal researcher's office.
A total of four interviewers were involved in the data collection. The face-to-face interviews were undertaken by interviewers who visited residents' homes in pairs. All four interviewers attended a briefing session on the same day and at the same time. The content and the structure of the questionnaire were discussed during this session. The briefing session was done on the day before the interviewers first entered the community. The interviewers were reminded of the importance of conducting interviews at every fifth home on entry of the community on the left then to cross over and do the same on the right before moving on and repeating that process on subsequent streets in the community. The debriefing session also involved a practice session with interviewing team members. Each interviewer had to act as a resident and was interviewed by his or her team interviewer. This gave the debriefing session leader an opportunity to spot weaknesses and take corrective action.
The analysis of this study was descriptive. Data processing was performed using IBM SPSS®, version 20. A T-test was used to compare males and females responses on the personal contact (PC), judgement (JS) and social support (SS) scales for alcohol, marijuana, cocaine and crack. Bivariate correlation was used to determine the relationship between the variables.

RESULTS
Survey respondents (n=121) ranged in age from 18 to 65. Thirty four percent (34%) of respondents fell between the 30-49 age cohort. The 18-29 and 50-65 age groups had 33% of respondents each. Half of the respondents (50%) were female, and more than half (66%) were single and 17% reported that they were married. Most of the respondents self-identified as religious (82%), while a small percentage (2%) did not know. Half of the respondents were unemployed (50%). Regarding education level, 46% had completed secondary school and half of the participants (50%) had completed beyond secondary level education. Most of the respondents (79%) knew someone who misused alcohol and 63% knew someone who misused marijuana. Conversely however, most of the participants did not know anyone who misused crack (82%) and 62% did not know anyone who misused cocaine. Almost all the sample participants (99%) reported that they have never used crack and 98% had no experience using cocaine. Most respondents (76%) reported that they have used alcohol and 31% reported they have used marijuana in their lifetimes. Table 1 depicts the residents overall attitudes toward those who abuse drugs. Residents displayed positive attitudes toward those who abuse alcohol and marijuana but were ambivalent towards those who abuse cocaine and crack. Table 2 shows the T-test comparison between male and female respondents' attitudes toward alcohol, marijuana, cocaine and crack across the attitudinal scales. The results of the two independent sample T-test shows a statistically significant mean difference between males and females attitudes on the personal contact scale for alcohol: t (119)=(-2.442), p-value=0.02 and personal contact scale for marijuana: t (119)=(-2.52), p-value=0.01.      Table 4 shows the correlates of the overall attitudinal responses toward alcohol, marijuana, cocaine and crack. Cocaine and crack displayed a very strong association followed by alcohol and marijuana displaying a strong relationship.

DISCUSSION
Societal attitude toward those who misuse drugs are often negative, yet residents' in this study ascribe priority in helping drug abusers through their responses on the social support and personal contact scales. Residents displayed ambivalent attitudes toward those who abuse cocaine. This finding provides opportunity for intervention measures geared toward changing such attitudes into positive ones.
On the attitudinal scales, the high level of support among respondents attitude for those who misuse alcohol and marijuana are related to the perception of the low risk attached to marijuana and alcohol misuse. On the personal contact scale, this study found a statistically mean difference between males and females on the personal contact scale for alcohol and marijuana.
Alcohol is a socially accepted substance and marijuana is endemic in the religious and cultural lives of some Jamaicans. 12 Marijuana use is high on the social and political agenda especially with Jamaica's decriminalisation of this substance in 2015, a move that has strengthened the view that it is the least harmful substance. 13 This belief held among the general population remains intact despite the proportion of treatment admission for marijuana in Latin America and the Caribbean increasing to 40 percent in 2015 and between 40 to 80 percent of persons reporting for treatment for drug use are diagnose with poly-drug use. 1 Further, studies have shown that marijuana use among adolescents is associated with increased risk for depression and anxiety disorders, chronic bronchitis and respiratory infections and deadly motor vehicle crashes. [14][15][16] Alcohol is both a legal and socially accepted substance in Jamaica. The social acceptability of this substance results in the public often ignoring its health risks. Yet, many studies have associated alcohol dependence with liver cirrhosis, and a high mortality rate in varying countries. 17 This research also found an association between residents' attitudes toward those who misuse cocaine and crack on the personal contact scale. A study of prejudice towards three minority groups in Australia with a sample size of 1,942 suggested some insight into residents' attitudes toward those who misuse cocaine and crack on the personal contact scale. 18 It found that in all cases, negative contact is a strong predictor of negative attitudes towards out-group members. Hence, negative experience with drug misusers is a strong predictor of negative attitudes toward them. Our study found that most of the respondents did not know anyone who misused crack (82%) or cocaine (62%). Hence, the results on the personal contact scale toward those who misuse cocaine and crack, as residents have little or no experience that could shape substantial negative attitudes on the personal contact scale.
Respondents' attitudes toward those who misuse drugs on the judgement scales for cocaine and crack revealed a very strong positive correlation. The majority of respondents displayed ambivalent attitudes toward those who misused cocaine and crack. Nevertheless, among all the four drugs, the residents displayed the highest negative attitude toward those who misused cocaine. The stigma associated with cocaine use is high in Jamaica although only 0.9 percent of the population aged 15-64 misuse cocaine. 1 Those who misuse drugs are among the mentally ill who face high levels of negative attitudes and this remains an obstacle to the provision of mental healthcare to treat them. One study instigating the internalisation and assimilation of stigmatizing attitudes, cognition and behaviours toward the mentally ill in Jamaica has found that the majority of respondents (66%) would avoid such persons and a sizeable percentage of the respondents (83%) were more likely to treat them unkindly. This study analyzed data from Jamaica's National Survey on Mental Health and included 1306 participants. 19 This cross sectional study is not representative of the entire country, hence findings cannot be generalised. The small sample size used may have misled parts of our results. Only persons between the ages of 18-65 years of age were selected.

CONCLUSION
The study used a cross sectional design to examine attitudes held by adult urban residents' in St. Andrew Eastern, Jamaica, about those who misuse drugs. Marijuana and alcohol have been perceived as being associated with lower levels of risks on the personal contact, social support and judgement scales. Public attitudes can help to shape what individuals deem a problem and the advices given to those who abuse marijuana and alcohol. Although the majority of respondents had no experience using crack and cocaine, their answers showed a strong positive relationship between the two substances. Respondents were more judgemental, displaying more negative attitudes toward those who misuse cocaine and crack than they did toward those who misuse alcohol and marijuana.
The attitudes of residents' toward those who abuse drugs are visibly absent from the literature. Most of the studies examine the attitude of varying professionals, for instance, nurses, doctors, psychiatrics', toward substance misuse. The present study provides some insights into the attitudes held by residents in a Jamaican community toward those who abuse drugs. This research represents an important first step in understanding these cultural attitudes and future research is required to examine the general Jamaican public's attitude toward those who abuse drugs.