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Texto & Contexto - Enfermagem

Print version ISSN 0104-0707On-line version ISSN 1980-265X

Texto contexto - enferm. vol.28 no.spe Florianópolis  2019  Epub Aug 15, 2019

http://dx.doi.org/10.1590/1980-265x-tce-cicad-11-11 

ORIGINAL ARTICLE

ATTITUDES TOWARDS PEOPLE WITH PROBLEMATIC DRUG USE IN THE CITY OF LOJA, ECUADOR

ATITUDES PARA COM AS PESSOAS COM USOS PROBLEMÁTICOS DE DROGAS CIDADE DE LOJA, EQUADOR

Cristina Alexandra Delgado1 
http://orcid.org/0000-0002-9589-6545

Bruna Brands2  3 

1Universidad Nacional de Educación. Azogues, Cañar, Ecuador.

2 University of Toronto. Toronto, Canada

3 Centre for Addiction and Mental Health. Toronto, Canada

ABSTRACT

Objective:

analyze attitudes toward people with problematic drug use in the city of Loja, Ecuador.

Method:

a quantitative, cross-sectional, preliminary study using survey methodology aimed at collecting data on attitudes towards people with problematic drug use by residents in the city of Loja, Ecuador. The sample size is 121 individuals. This study is part of a multi-center investigation that involves 10 universities and a National Drug Council in Latin America.

Results:

the results revealed that attitudes toward people with problematic uses of alcohol are positive while attitudes toward people with problematic uses of other drugs such as marijuana and cocaine are ambivalent. It also shows that ambivalence prevails according to the majority of socio-demographic variables, differing in the masculine gender, people in the range of 18-29 years; those who lives with their partner; those who have a higher education than high school who have a positive attitude towards people with problematic uses of alcohol. And the scale that presents the greatest difficulties is the area of personal contact with negative attitudes towards the users of marijuana and cocaine.

Conclusion:

it is vital to continue researching about stigma, social distance and attitudes towards people who use drugs in the Ecuadorian context, its impact on treatment and social integration and the most appropriate information strategies to avoid stigma.

DESCRIPTOR Knowledge; Attitude to health; Street drugs; Alcoholism; Marijuana Use; Cocaine

RESUMO

Objetivo:

analisar as atitudes para com as pessoas com usos problemáticos de drogas, na cidade de Loja, Equador.

Método:

estudo quantitativo, transversal, preliminar, que utiliza metodologia de questionário destinado à colheita de dados sobre as atitudes para com as pessoas com usos problemáticos de drogas, moradores na cidade de Loja, Equador. A amostra foi composta por 121 indivíduos. Esta pesquisa faz parte de uma investigação multicêntrica que envolve 10 universidades e 1 Conselho Nacional de Drogas na América Latina.

Resultados:

os resultados revelaram que as atitudes para com as pessoas com usos problemáticos de álcool são positivas, mas as atitudes para com as pessoas com usos problemáticos de outras drogas, como maconha e cocaína, são ambivalentes. Demonstra, também, que a ambivalência predomina de acordo com a maioria das variáveis sociodemográficas, diferindo no gênero masculino, pessoas na faixa etária de 18 a 29 anos, aquelas que moram com o companheiro, aquelas com nível superior de escolaridade - maior ao colegial - que têm uma atitude positiva perante pessoas com usos problemáticos de álcool, e a escala que apresenta maior dificuldade é a área de contato pessoal com atitudes negativas em relação aos usuários de maconha e cocaína.

Conclusão:

é vital continuar pesquisando o estigma, a distância social e as atitudes em relação às pessoas que usam drogas no contexto equatoriano, seu impacto no tratamento e na integração social, e as estratégias de informação mais apropriadas para evitar o estigma.

DESCRITORES Conhecimento; Atitude frente à saúde; Drogas ilícitas; Alcoolismo; Uso da Maconha; Cocaína

INTRODUCTION

Problematic drug uses should be looked at from historical, political, social, economic contexts. Each use is different and the problematic may be related in part by the observer eye that hinders access to services and social integration. In Ecuador, drug use is considered a public health problem,1 and from this way of situating the phenomenon it is important to consider that one of the difficulties in terms of mental health problems is the stigma that surrounds them.2 In the text “Drugs: between regulated bodies and deviated moral. Argentina, 1880-1960” indicates how in Argentina the use of drugs is related from politics and practice to the immoral, deviant and intrinsically dangerous.3 The drug-crime, drug-danger relationship impacts on the exercise of citizenship of drug users, access to their rights, such as health and deepens exclusion.4

A study indicates that there is stigmatization towards the mentally ill which has a negative impact on them.5 The results of the study show that people who are part of the health area and who knows and have closeness to people with mental illness have less stigmatization behaviors which positively influences their treatment and prognosis. Stigma can vary according to socio-demographic data, younger people tend to have less negative attitudes, in the same way people with a higher cultural level, more knowledge and contact with people who have mental health problems.2

Stigmatization generates groups of people who see their exercise of rights conditioned. Drug users are one of these groups, and it is important to study stigma processes as a barrier to access to health care, and the exercise of rights in general. To identify components that reduce this exclusion.6 Study indicates that the stigma towards people who use drugs in adolescents, is higher than in people of older ages, this being a barrier to treatment.7

In 2012, the Fourth National Survey on Drug Use in Students from 12 to 17 years of CONSEP revealed that the average age of first use was 14.2 years for alcoholic beverages, 14.1 years for cigarettes, 14.8 years for marijuana, 14.7 years for cocaine, 14.3 for cocaine base paste and 13.5 years for inhalants.* In 2013, the Fourth National Study on Drug Use in Population aged 12 to 65 years revealed that 16.7% of men and 9.8% of women had consumed alcoholic beverages in the last 30 days prior to the survey; the prevalence for the month was 13.0%. In addition, 11.4% of men and 5.4% of women had used cigarettes in the past 30 days; the prevalence of the month was 8.1%. In relation to illicit drugs, 0.41% of men and 0.06% of women reported using or consuming marijuana in the last 30 days; the prevalence of the month was 0.22%. Regarding the reaction to this population of people who use drugs, the interviewees indicated that 43.5% feel pity or shame; 23.6% fear and 8.9% rejection. The remaining 24% do not want to interact with any person who uses drugs or have no reaction, is indifferent to people who use drugs.** Additionally, a study conducted at the University of Manabí, Ecuador, reveals that the most commonly used drugs in the last 12 months were alcohol and tobacco, with 52.8% and 24.4%, respectively.8 In turn, another study conducted at the University of Salvador indicates that the most commonly used drugs are alcohol, tobacco and cannabis.9

A study of social perception, carried out in the city of Quito-Ecuador, investigated how individuals react to people with problematic uses of drugs. The most common response was: wanting to help 30.2%, followed by grief and pity 25.2%, fear 22.9%, rejection 8.3%, no particular reaction 10%, and did not want to know anything about them 2.3%.10

Therefore, it is necessary to continue with studies that analyze attitudes and perceptions towards people who use drugs that allow generating policy and practices that allow addressing stigma and reducing barriers to accessing services and social integration.

This study is part of a multi-center investigation that involves 10 countries in Latin America to analyze the attitudes toward people with problematic drug use, and can help us understand the difficulties for attention and access to public and private services of problematic drug users; as well as to inform public policy about possibilities to reduce stigma and promote social integration in this phenomenon.

For the analysis, the ecological theory was used to determine if the attitude is positive, negative or ambivalent and if there is a relation of attitudes according to socio-demographic variables and the drug used.11-12

The objective was to analyze attitudes towards people with problematic drug uses. This can help us to understand the difficulties for attention and access to public and private services of problematic users and drugs, in the city of Loja, Ecuador.

METHOD

Descriptive and cross-sectional study of quantitative approach, which uses a survey and examines the attitudes of people from the city of Loja-Ecuador, towards individuals with problematic uses of alcohol, marijuana and cocaine. Since this research is part of a multi-center study, the sample size for each country was determined in 121 individuals as recommended.13-14

The selection of the sample was carried out following three steps established in the research manual developed for the multi-center study: “Attitudes toward people with problematic drug use in ten urban communities in Latin America and the Caribbean.16 First the selection of the urban community in this case the city of Loja, then the selection of the neighborhoods and dwellings in a random way and finally the selection of the participants of each dwelling. The main researcher with the help of the Private Technical University of Loja compiled data from INEC and the Municipality of Loja to make the selection.

The inclusion criteria were any house with at least one adult between 18 and 65 years old in the destination community that can give their informed consent and that has the same probability of being selected at random to be part of this study. And those of exclusion: 1) Any building that is not a dwelling per se, 2) Any house that does not house potential participants or that is empty at the time of data collection. Anyone under the age of 18 was also excluded from the sample, even the emancipated minors who were able to provide informed consent. It also excludes any person who is 18 years of age or older, who is not able to give informed consent or who for some type of disability could not give a reasonable response. For the measurements, the Multidimensional Attitude Inventory (MAI) was used, applied to 121 people between 18 and 65 years old, considering the same number of participants according to gender. The instrument was experimented with 15 participants. After which, without change, the application of the survey to the determined sample continued. For the collection of data, the city of Loja was chosen because it is a city with a number of inhabitants between 5000-10000 and to be considered urban, as indicated in the manual for multi-center research.15

For the data collection the students of Private Technical University of Loja, were trained by the main researcher and later a schedule was made for the collection of information and places for the collection by neighborhoods in the City of Loja. The selection of the neighborhoods in which the information was collected were made with INEN data so that all the neighborhoods are considered and to verify that the places to visit are inhabited and belong to the urban area. The sample for the selection of households was made at random. For the selection of participants in each household, 50% of men and 50% of women were considered, so the interviewer had to verify this condition in the sample. In the same way, the interviewer verified that the sample contains people from each age range (18-19, 30-49, 50-65).

However, when a person in the required age group was not available at home, the interviewer selected an eligible person in any age group between 18 and 65. In addition, the interviewer carried out a verification in the middle of the sample to verify that the same number of surveys are being collected by gender and age range. In cases where this was not fulfilled, the interviewer conducted oversampling to ensure that the size of the strata meets in the second half of the data collection.

The data were processed with the SPSS program version 20 and its analysis was performed by descriptive statistics as well as contingency tables, Chi-square and T-Student to examine the associations. Scales were used: personal contact, judgment and social support.

The three scales are obtained in the same way. Scores of different scales will vary from 5 to 25. This is 5 (1x5) or a mark for each item on the scale up to 25 (5X5).

Therefore, a person presents a positive attitude if he answers the 5 elements and gets between 3 and 10, ambivalent if it is between 11 and 19 and have negative attitudes if they get between 20 and 25 (Chart 1).

Chart 1 - Classification of the Multidimensional Attitude Inventory Scale by scales of personal contact, judgment and social support, 2018. 

Number of items answered Positive scores Ambivalent scores Negative scores
5 items 5 to 10 11 to 19 20 to 25
4 items 4 to 8 9 to 15 16 to 20
3 items 3 to 6 7 to 11 12 to 15
Average scores 4 to 8 9 to 15 16 to 20
Less than 3 answers discarded

Because MAI is an accumulated inventory each of its different scales can be marked separately and added together to create the total attitude scores. When all 15 inventory items are completed, total scores between 15 and 44 indicate positive attitudes across the domains. Scores between 46 and 59 indicate ambivalence while scores between 60 and 75 indicate negative attitudes. Inventories with less than 10 units attended should be discarded according to the manual for the investigation; however, this was not necessary in this case.

RESULTS

Table 1 indicates the socio-demographic data of the sample. The majority, 66.7%, of the participants had a job; 87.6%, had a religious belief; 60.2% were married consensually married; 74.4% had a high school or higher education level; 94.1% had used alcohol at some time in their lives; 76%, had not used marijuana; 97.4% had not used cocaine; 86.8% know someone with problematic uses of alcohol; 55.5% do not know someone with problematic uses of marijuana; 74.6% do not know someone with problematic uses of cocaine.

Table 1 - Socio-demographic characteristics of urban residents of the city of Loja, Ecuador, 2014. (n=121) 

n %
Gender
Male 60 49.6
Female 61 50.4
Age range
18-29 41 33.9
30-49 40 33.1
50-85 40 33.1
Job
Employed 76 66.7
Unemployed 38 33.3
Religious belief
Not religious 10 8.8
Religious 99 87.6
Do not know 4 3.5
Civil status
Single 30 25.4
Consensually married 14 11.9
Married 57 48.3
Widow/Widower 1 .8
Divorced 6 5.1
Separated 10 8.5
Level of education
Not formal 2 1.7
Elementary school 29 24.0
High school 36 29.8
Above high school 54 44.6
Have ever used alcohol
No 27 22.3
Yes 92 76.0
Do not know 2 1.7
Have ever used marijuana
No 111 94.1
Do not responded 7 5.9
Have ever used cocaine
No 114 97.4
Yes 3 2.6
Know someone with problematic uses of alcohol
No 16 13.2
Yes 105 86.8
Know someone with problematic marijuana uses
No 66 55.5
Yes 53 44.5
Know someone with problematic cocaine uses
No 88 74.6
Yes 30 25.4

Figure 1 shows the attitudes means toward people with problematic uses of alcohol, marijuana and cocaine, according to each MAI scale. It is observed that the scale with less favorable attitudes is the scale of personal contact. People present negative attitudes on the scale of personal contact in relation to people who use cocaine (20.51), followed by marijuana (19.92) also in the range of negative attitudes and finally by alcohol (18.10) in the range of ambivalent attitudes. Also in Figure 1, it can be seen that the scale that follows in the score is the Social Judgment scale with attitudes considered as ambivalent.

Figure 1 - Average attitudes according to MAI scales and type of drug, city of Loja, Ecuador, 2014 

Table 2 indicates the average of attitudes towards people with problematic uses of alcohol, marijuana and cocaine. It is evident that attitudes towards people with problematic uses of cocaine are in the range of ambivalent with 46.64, followed by attitudes towards people with problematic uses of marijuana also in the range of the ambivalent ones with 45.62. And finally, attitudes towards people with problematic uses of alcohol in the range of positive ones with 42.21 as average. Less positive attitudes are directed towards people with problematic uses of cocaine.

Table 2 - Average attitudes according to type of drug, city of Loja, Ecuador, 2014. (n=121) 

n Minimum Maximum Half Standard deviation Attitude
Attitudes toward Alcohol 119 25 61 42.21 6.946 Positive
Attitudes toward Marijuana 117 22 63 45.62 6.917 Ambivalent
Attitudes toward Cocaine 116 26 60 46.64 5.617 Ambivalent

Table 3 presents the means of attitudes towards people with problematic uses of alcohol, marijuana and cocaine according to whether the persons surveyed stated that they knew someone with problematic uses of cocaine. The results indicated that people who report not knowing anyone with problematic uses of cocaine have attitudes in the range of ambivalent toward people with problematic uses of alcohol, marijuana and cocaine. In the case of people who did report knowing someone with problematic uses of cocaine, attitudes are in the range of positive towards people with problematic uses of alcohol and marijuana, and ambivalent towards people with problematic uses of cocaine.

Table 3 - Average attitudes towards people with problematic uses of alcohol, marijuana and cocaine, depending on whether they know someone with problematic uses of cocaine, city of Loja, Ecuador, 2014. (n=121) 

Attitudes towards people with problematic uses of Yes, you know No, you do not know
Alcohol 39.79 43.03
Marijuana 42.43 46.67
Cocaine 45.11 47.16

DISCUSSION

The study shows that the area of personal contact is the one that presents the greatest difficulty, with less favorable attitudes, evidencing that people present negative attitudes towards the users of marijuana and cocaine and ambivalent towards the users of alcohol in this scale. One study mentions that despite the stigma towards drug users there is still not enough research on this topic. This study shows that there is more stigma towards heroin users than marijuana users and that there is more stigma towards marijuana users in people who consider users severe and less controllable cases. It is recommended to analyze the stigma substance by substance.17

On the other hand, research suggests that men's social distance to women who use drugs is often less than the distance to men who uses drugs.18 However, the social distance in general towards drug users, people with obesity and homosexual persons is greater than the social distance towards a person without these characteristics. Another study indicates that the familiarity with the drugs marijuana and heroin is related to greater social distance considering the people who uses these drugs as dangerous and fear them.19

An investigation carried out in China mentions that the majority of people present a great social distance towards drug users and suggests that the treatment system of the mentioned country consider this for their interventions.20 The mentioned thing could be important to be consider in Ecuador. However, there is a discrepancy between the attitudes that drug users sense from health professionals and the attitude that health professionals consider to have toward drug users, besides, attitudes vary according to the type of drug used.21

The study shows that attitudes on the general scale toward people with problematic uses of alcohol are positive while attitudes towards people with problematic uses of other drugs such as marijuana and cocaine are ambivalent. It also shows that ambivalence prevails according to the majority of socio-demographic variables, differing in the masculine gender, people in the range of 18-29 years old, those who are consensually married, those who have a higher education than high school who have a positive attitude towards people with problematic uses of alcohol. Studies indicate that women tend to have more stigma towards people who use drugs.22

The use of alcohol is widely accepted 23 and since alcohol is the most widely used drug in the country and socially accepted, we look at how attitudes towards people with problematic uses of alcohol are positive and mainly in male populations that culturally have less social reproach for the uses of alcohol and other drugs. In addition, the age range of 18 to 29 years is a period in which, according to the national study on drugs 2014 conducted by CONSEP, the most intense uses of alcohol in general population are found. However, a study indicates that the social distance to alcohol users is lower and attitudes are more positive when the drinker is male and is not in the group of best friends.24 People with higher education then high school have positive attitudes towards people with problematic uses of alcohol. In this sense, a study on perception towards people with mental health problems indicates that people who have close contact and health education have better perception of this population group.5 According to the mentioned study, the information generates more positive perceptions, which can be an opportunity for social integration processes.

According to whether the interviewee stated that he has used alcohol, marijuana and/or cocaine, the attitudes toward people with problematic uses of the mentioned drugs vary, being more positive in those who use marijuana and/or cocaine. It is important to see that attitudes tend to be more positive in groups that could be excluded because of their uses. The drug alcohol has a great impact on the health condition of the population in our country; however, those who use alcohol for being an accepted drug do not have so much social reproach and are those who have ambivalent attitudes towards people with problematic uses of marijuana and cocaine and positive for the drug alcohol. On the other hand, studies conducted in Africa indicate that people have a negative perception for both alcohol and cannabis, however, they are mostly willing to help a woman and push for mandatory treatment for men, this fact invites us to reflect on the social role, the context and imaginaries about drugs. In addition, people who scored higher on ASSIST have more negative attitudes towards drug users and Afro-descendants had attitudes related to the aid of people who use drugs.25 Because of the mentioned stigma in South Africa is not directly associated with the used drug, however, there are factors such as gender, ethnicity that impact on stigma.

On the other hand, people who use marijuana and cocaine have positive attitudes towards people with problematic uses of alcohol, marijuana and cocaine. It is important to look at intervention opportunities in the linking of different types of drug users for work in improving attitudes towards people with problematic uses of drugs that facilitate their therapeutic accompaniment, social integration and their quality of life in general. Including people who use drugs in the design of drug programs and policies can be important to consider their difficulties in social integration, as well as the information they possess that apparently influence so that the attitudes toward problematic drug users are more positive.13

Depending on whether the interviewee knows someone with problematic uses of alcohol, marijuana and/or cocaine, their attitudes vary, being more positive in those who know people with problematic uses of cocaine. People with higher education than high school, those who have used mentioned drugs and those who know people with problematic uses have more positive attitudes towards people with problematic uses of alcohol, marijuana and cocaine. This may be due to more information about drug use attitudes towards people with problematic uses can be more positive, so it could be seen as an opportunity for social integration processes.

The fact that people who use drugs present more positive attitudes towards people with problematic uses of alcohol, marijuana and cocaine, could show opportunities in the area of stigma reduction, and work in social integration from the perspective of the drug user. A research indicates that information via videos generated more favorable attitudes toward medicinal cannabis users.26 In addition, in this study it is observed that the participants who saw narratives in which the protagonist had a stigmatized disease and was responsible for contracting his disease had more negative attitudes towards medicinal marijuana. The above can generate reflections on the information strategies that can be used to reduce the stigma towards people who use drugs.

The information and knowledge in greater depth about the use of drugs and especially the problematic use may be related to the reduction of stigma. A study on stigma towards people diagnosed with schizophrenia mentions that one of the main causes of stigma is the lack of information or de-virtualized information, therefore an opportunity for reducing stigma may be associated with timely information and you will see about the problematic uses of drugs. Information based on science and also on the experience of the user can be an important variable for the construction of new imaginaries about drugs, their uses and their associated problems.27-28

As limitations, we find that this study can not be generalized for the whole country because the size of the sample and the place of collection only represents the urban residents of the city of Loja. As it is an experimental study it will be necessary to continue with more research on this topic for better understanding.

CONCLUSION

There are still not enough studies in Ecuador on stigma, social distance and attitudes towards people who use drugs, which is why this study contributes greatly to the first approaches to a topic that may affect the treatment and integration areas of people who use drugs. Also contributes to the reflection on the need for truthful, pertinent and timely information about drug users to avoid their stigmatization.

It is important to reflect and continue on researching on socio-demographic variables such as age and gender and its relationship with stigma towards people who use drugs and opportunities for improvement in social integration and treatment processes.

The greatest difficulty for the social integration of people with problematic uses of drugs is in personal contact, being a need to investigate how they are presented and the strategies to overcome it. At the same time, the need to investigate the impact in this area according to the context and type of drug is observed.

It is recommended to conduct more research around the attitudes of the population towards people with problematic drug use in Latin America, the stigma, and their possible strategies to overcome it. On the other hand, extending this study to all areas of Ecuador and the region would be important to analyze the differences and similarities in terms of the attitudes of the population towards people with problematic uses of drugs.

ACKNOWLEDGMENTS

To the Government of Canada-DFAIT, the Organization of American States, the Inter-American Drug Abuse Control Commission, the Addiction and Mental Health Center of Canada, and the Private Technical University of Loja and to the participants of the study sample and other people who collaborated directly or indirectly in the study.

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NOTES

ETHICS COMMITTEE IN RESEARCH Ethical approval was obtained from the Research Protocol of the multi-center study No.109/2013 by the Research Ethics Committee of the Center for Addiction and Mental Health of Canada and the approval of the National Council for Narcotic and Psychotropic Substance Control by Memorandum on December 9, 2013.

Received: June 19, 2018; Accepted: April 01, 2019

CORRESPONDENCE AUTHOR Cristina Alexandra Delgado cristina.delgado@unae.edu.ec

CONTRIBUTION OF AUTHORITY

Study design: Delgado CA, Brands B. Data collect: Delgado CA. Data analysis and interpretation: Delgado CA, Brands B. Discussion of the results: Delgado CA, Brands B. Writing and / or critical review of content: Delgado CA, Brands B. Review and final approval of the final version: Delgado CA.

CONFLICT OF INTEREST

There is no conflict of interest.

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