Ups and downs of drug rehab among women: a qualitative study

Abstract

Background

According to recent studies, the number of women drug users is dramatically increasing. However, the information on the issue of drug rehab in women is not sufficient, and there are numerous traditional, organizational, political and cultural barriers to the provision of relevant information in this regard in Iran. This study, thus, aimed to explain the factors influencing the decision of these women to stop drug use.

This qualitative study was conducted in two rehab camps of Isfahan (in Iran) on July to October 2017. Thirty participants (women drug users) were selected through purposive and theoretical sampling until data saturation was reached. Data collection was conducted through semi-structured interviews. The transcribed interviews were analyzed using conventional content analysis.

Based on the analysis of the obtained results, the women’s experience of the ups and downs of stopping drug use yielded two themes and nine sub-themes. The themes were “the need for emancipation (the deviated path, being abused, compulsive drug use, acquaintance with God, a supportive family)” and “Sinking factors (non-assisting mates, pro-addictive family, unawareness of assisting official organization and non-government organization, woman’s lack of authority, ineffective opportunities)”.

Conclusions

It was concluded that addiction rehab strategies can lead to a brighter life for women drug users only when they are coupled with open-hearted assistance of the families and women specific rehab centers are established to help them meet their specific needs.

Introduction

Substance-related disorders are among the disorders which have much personal, familial and social harm associated with increased tension in the family and abusive behaviors [1]. There are 230 million drug users all around the world, accounting for about 5% of the world’s population [2]. There is no clear report about the precise number of drug users in Iran. Reviewing various domestic sources, Sarrami (2013) reported officially that there are about 1,200,000, drug users in Iran; however, according to the report of unofficial sources by various experts and officials, this number is up to 5 million. The significant point in this regard is that the current situation and the process of drug use in Iran are alarming and deteriorating [3]. As the classic form of drug use consists of a male pattern, drug use is more a masculine than a feminine problem [4]. However, recent studies indicate that the number of women drug users is growing. The proportion of women drug users is estimated to range from 10% in Asian countries to 40% in European countries [5].

The results of a survey in Shiraz, in the southern part of Iran, showed that about 3% of the subjects had used heroin at least once in their lifetime [6]. In the 1970s, 4.5% of the drug users were estimated to be women; however, this ratio has increased to 10% according to the official statistics in Iran [7]. Because of the factors such as stress, negative mood in relationships, turbulent and violent family environment, addicted spouses, psychiatric illnesses and sexual violence in women, they are more likely than men to be involved with drug use [8]. Khademian (2008) stated in a study that disruption in the conjugal life of husband and wife, disintegration of the parental life, problems in the conjugal life of the couples, socioeconomic problems, drug availability, and family members’ drug use are among the factors affecting the use drug in Iranian women [9]. Although drug use is less common in women than in men, it has higher medical, social and economic consequences in women. These consequences include unwanted pregnancy, trauma, violence and transmission of infectious diseases such as HIV (human immunodeficiency viruses) and hepatitis B and C [10]. Additionally, social harms such as runaway, prostitution, and high-risk behaviors are among the harms associated with drug use in women [7] which endanger their health and challenge their rehabilitation process [11]. Various studies have identified factors effective in the decision of the drug users to stop drug use. Negative attitudes toward women drug users, lack of family and friends support (compared to the male ones), economic poverty, redundant bureaucracies, the focus of rehab programs on men, and the lack of specialist rehab centers for these women are among the barriers to the rehabilitation of them [11]. McDonnell (2010) showed in a study that the most important factors in finding a way for drug detoxification include the drug users’ understanding of the negative effects of drug use on themselves and others, social deprivations, drug-related stigmatization, imposed heavy costs, negative impact of drug use on the communication with others and family members, inability in doing their job and duties, lack of control over life, and the incidence of physical, mental and social illnesses which make drug users think about the problem and try to stop drug use [12].

The results of the study by Herd (2009) showed that being aroused and tempted to use drug and the motivation and hope to stop drug after using it, together with the lack of self-efficacy and self-esteem are among the important factors of relapsing into drug use [13]. Moreover, labeling is one of the factors contributing to the relapse of drug use. In addition, factors such as addicted friends, psychological stress, referring to the former locations or hangouts, unpleasant situations, being rejected by the family and society, and seeing the tools and objects of drug use are other factors in this regard [14]. Studies have shown that religion and its related variables decrease suicidal behaviors [15] and drug use [16]. Unfortunately, numerous studies have shown that there is a high likelihood of relapse into substance use after stopping it. Some studies show that the relapse of drug use has occurred within the first 6 months in 80% of those who have referred to rehabilitation centers to stop drug use [17]. According to the available statistics, drug users refer to rehabilitation centers more than 2 to 3 times, suggesting that the rate of relapse is dramatically high [18]. Accordingly, it seems that more accurate, broader and deeper preventive and therapeutic interventions should be considered for these people in the society. This will not happen unless we identify the factors associated with the treatment of drug users as well as all of the factors effective in this regard and present them in an accessible format. But the society does not have the understanding and capacity to provide services for women drug users, and these women are seen as abusive individuals [19]. Although numerous studies have been conducted on drug-dependent subjects and drug-dependence as a whole, most of them have not considered women as their subject [20]. The growing number of drug-dependent women is one of the important social issues in Iran. Drug rehabilitation has been an issue of concern for authorities, drug users themselves and their families as well. This issue is more important especially in developing and young countries, including Iran, which need more efficient and effective human resources [21]. Although many studies have been conducted on drug use and drug rehabilitation all around the world and in Iran as well [22, 11], less attention has been paid to the decision-making process in this regard. An individual’s attitudes, behaviors, and values construct an important part of the change process [14]. Therefore, the present study was conducted with a qualitative approach in order to develop a deep understanding of the challenges and opportunities of women drug users in their decision to stop drug use through using their experiences. This study thus aimed to explain the factors influencing the decision of these women to stop drug use.

Methods

This qualitative study was conducted in two rehab camps of Isfahan in July to October 2017. Isfahan is located almost in the center of Iran. Isfahan is the third most populous city after Tehran and Mashhad, with an estimated urban population of 2,243,249, 49% of which are women. The people of Isfahan also have a traditional religious culture. Isfahan has two drug rehabilitation camps specifically for women drug users, which are located in the outskirts of the town. Women, who come to these centers for drug rehabilitation, can stay there for 21 days and have to pay for it. No medication is allowed during these 21 days and they can meet only a counselor or other drug users. These women are often self-proclaimed and coming from their families, law enforcement or friends. After leaving the camp, there are no coherent and appropriate managed services to help the sustainability of drug rehabilitation. These two camps are for women drug users, covered and supervised by the Welfare Organization. The researcher has been able to conduct interviews at these two sites by introducing herself through a written letter and following difficult administrative procedures.

The participants were selected by using purposive sampling method from 30 women who had drug use related experiences. Inclusion criteria were having experience of being in a drug rehabilitation process, being volunteer to participate in the study, aged 18 to 50, and having the ability to express their experiences. Exclusion criteria included having any known mental illness (Based on the counselor’s view in rehab camps), the inability of the participant to take part in the interview and answer the researcher’s questions, and having sensory, hearing and speech impairments that might affect the process of the interview and data collection. All 30 participants were interviewed by the first and third authors through a semi-structured interview in the Camp Consultant Office in a quiet and private environment. Besides the selection criteria, we aimed to obtain a diverse range of participants in terms of age, marital status, educational level, and socioeconomic condition.

After selecting the participants according to the study’s inclusion criteria and obtaining the consent of the interviewees, the time and place of the interview was determined. Before the interview, the participants’ permission and consent was obtained for recording the interview. The interviews were recorded by a voice recorder. The voice recorder was placed in front of the participants and, before recording their voice, their permission was obtained. Then, they were asked to identify themselves with a pseudonym. The researcher conducted deep face-to-face and semi-structured interviews with the participants and each interview began with a guiding question. At the beginning of the interview, certain questions were asked so that the researcher could become familiar with the interviewees, gain their confidence, create a safe and relaxed atmosphere, and gain as much information as possible about their personality. Then, open-ended questions like “under what conditions did you start substance use?” “Why did you stop using drugs?” “What has been your experience with drug rehabilitation?” were asked. The next follow-up questions were made based on the participants’ explained experiences. Questions such as “what do you mean?” “Please explain more.” “ Did I get what you mean correctly?” were used to deepen the interviews. All of the questions were designed to deepen the level of understanding. The duration of the interviews ranged between 45 to 60 min based on the physical and psychological conditions of each subject and continued until data saturation was reached. In order for more intimacy to be brought about, the first and third authors spent time in the camps with the subjects before and after each interview. They ate with the participants for a few days and talked about a common topic other than drug use.

Conventional content analysis [23] of the transcribed interviews and field notes was performed to identify key themes, first by each of us separately and then in joint discussions. During analysis, we avoided preconceived categories, instead allowing the categories to flow inductively from the data. After conducting the interviews, all of the audio files were transcribed and typed verbatim from an audio digital recorder. Next, the transcripts were classified into categories of sentences or paragraphs that were, then, changed to meaning units. We took notes listing our first impressions and thoughts and, then, conceive labels for codes used as an initial coding scheme. Then, the meaning units were collected, summarized, and coded. We then sorted the codes into categories based on relations and links among them. This step was repeated several times until the semantic units extracted from the texts can cover all experiences of the participants with regard to the rehabilitation process and its challenges. Finally, the compilation of the themes was performed to draw the hidden content of the text. We believe that although the described sample was not large, it was unique and might be considered meaningful. When data saturation was reached, sampling was discontinued. In fact, according to the conventional analysis of the qualitative data, when the data in open coding are similar and no new data is found, the interview is terminated and data saturation is reached. The process of data analysis was repeated after each interview, and codes and categories were modified if necessary. The credibility of the data was established by the researchers as a peer check. The data were coded and categorized independently by the first and second authors and, then, the emerging themes were compared. When the authors disagreed, clarifications and discussions continued until a consensus was achieved. We emphasized 80% agreement on the codes. Common eligibility criteria of qualitative research such as verification, reliability and transferability were taken into account in the study through techniques. Therefore, a summary of the interviews was returned to the participants as a member check to confirm that the researcher represented their ideas. Moreover, trustworthiness of the research was established through prolonged engagement with data, constant comparison analysis, and maximum variation of sampling, systematic data collection, quick prescription, using the participants’ views, and reviewing all of the data. Transferability of the research was also confirmed through interviewing various participants.