Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 38-42

Twin-center study comparing stigma among males and females with alcohol dependence


1 Department of Psychiatry, Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore, Karnataka, India
2 Abyudaya Center for Humanity and Rural Development, Integrated Rehabilitation Center for Addiction, Tumkur, Karnataka, India

Date of Submission02-Feb-2020
Date of Decision04-Apr-2020
Date of Acceptance08-Apr-2020
Date of Web Publication9-Jun-2020

Correspondence Address:
Dr. Megha Sadashiv
Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SHB.SHB_14_20

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  Abstract 


Introduction: Alcohol dependence is a complex disorder that affects brain function and behavior, characterized by impaired functioning, causing considerable harm to the individuals with the disorders and to society as a whole. Stigma associated with substance use is considered a significant barrier to detection and treatment efforts, and research is needed to understand and address this issue. This study aimed to assess and compare stigma among males and females with alcohol dependence. Methods: The twin-center study involved 70 patients with alcohol dependence, which included 35 males and 35 females from the Department of Psychiatry, Yenepoya Medical College, Mangalore, and Abyudaya Center for Humanity and Rural Development, Integrated Rehabilitation Center for Addiction, Tumkur, India. The mean age of males was 39.14 years and females 41.00 years. The Substance Use Stigma Mechanisms Scale was used to assess stigma. The study had outpatients and inpatients who were above 18 years of age and diagnosed with alcohol dependence as per the ICD-10 criteria, not under the influence of alcohol at the time of interview and without any comorbid psychiatric illness except nicotine dependence. Results: The study showed anticipated stigma more in females (mean: 2.30) compared to males (mean: 1.91) which could be a significant factor for treatment-seeking behavior. Internalized stigma was more in males (mean: 3.84) compared to females (mean: 2.90). Enacted stigma did not show a significant difference between the two genders in our study. Conclusion: Persons with alcohol dependence experience stigma, and we found that there is a gender difference. Stigma associated with substance use is considered a significant barrier to detection and treatment efforts. Understanding various aspects of stigma will help in providing better management.

Keywords: Addiction, alcohol dependence, stigma, Substance Use Stigma Mechanisms Scale


How to cite this article:
Sadashiv M, Kakunje A, Karkal R, Ganganna SH. Twin-center study comparing stigma among males and females with alcohol dependence. Soc Health Behav 2020;3:38-42

How to cite this URL:
Sadashiv M, Kakunje A, Karkal R, Ganganna SH. Twin-center study comparing stigma among males and females with alcohol dependence. Soc Health Behav [serial online] 2020 [cited 2021 Dec 2];3:38-42. Available from: https://www.shbonweb.com/text.asp?2020/3/2/38/286257




  Introduction Top


Alcohol dependence is a complex disorder that affects brain function and behavior, characterized by impaired functioning, causing considerable harm to the individuals with the disorders and to society as a whole.[1] Although evidence-based treatments exist, a large gap exists between the number of those with this disorder and those who receive treatment.[1],[2],[3],[4] To address this gap, the National Institute on Drug Abuse has recently identified understanding and decreasing the stigma of substance use disorders (SUDs) as a major priority.[5]

To frame our review, we utilize three major stigma concepts from a major sociological framework that elucidates how societal forces exclude stigmatized individuals from everyday life.[6],[7],[8] The first, stereotyping, occurs when public conceptions link labeled individuals to negative characteristics, for example, viewing people with SUDs as dangerous. The second is emotional reaction, the affective responses to stigma endorsed by the general public (e.g., fear and disgust) toward those with SUDs. The third concept, status loss and discrimination, occurs when individuals with SUDs are perceived as less valued and treated unjustly (i.e., discriminated against) by others. Discrimination can occur either when individuals are treated unfairly by another person or when institutional practices are discriminatory to individuals with SUDs.[9]

Stigma associated with substance use is considered a significant barrier to detection and treatment efforts; research is needed to understand and address this issue.[10],[11],[12] As such, substance use stigma can manifest at structural, social, and individual levels. Substance use stigma at the structural and social levels reflects a core consensus that society, as a whole, devalues persons with SUDs and legitimizes collective action to penalize this population through institutionalized systems, policies, and practices.[13],[14] Specifically, stigma theory suggests that structural and social stigma associated with substance use is experienced by individuals as enacted, anticipated, and internalized stigma.[15]

The psychological theories describe ways in which individual people living with and without socially devalued and discredited characteristics enact, perpetuate, and perceive this social process.[16],[17],[18] The stigma framework identifies measurable stigma mechanisms from this literature, which reflects an individual's distinct psychological responses to the knowledge that they possess a socially devalued and discredited characteristic, including enacted stigma, anticipated stigma, and internalized stigma.[19] These stigma mechanisms are ultimately related to physical, mental, and behavioral health outcomes. The stigma framework further specifies that these mechanisms are related to, but function independent of each other, and are important to measure given their unique associations with the health and well-being of stigmatized individuals.[20] Enacted stigma reflects personal experiences of stereotyping, prejudice, and/or discrimination from others in the past or present due to one's stigmatized attribute.[21] Anticipated stigma reflects expectations of stereotyping, prejudice, and/or discrimination from others in the future due to one's stigmatized attributes.[22] Perceived stigma is the process through which stigmatized individuals recognize the prevalence of stigmatizing attitudes and actions in the general public toward individuals who belong to their stigmatized group.[23],[24] Studies on alcohol dependence are largely on male populations; stigma is a less explored topic among females. Hence, we set out to assess and compare stigma among males and females with alcohol dependence.

The aim of this study is to assess and compare stigma among males and females with alcohol dependence.


  Methods Top


It is a twin-center, cross-sectional study, conducted at the Department of Psychiatry, Yenepoya Medical College, Mangalore, and Abyudaya Center for Humanity and Rural Development Integrated Rehabilitation Center for Addiction, Tumkur, India. The sample size was calculated using internalized stigma (R2 = 0.637) with α % level of significance of 0.01 ≥1% and power at 80%. The estimated sample size was 70, in which 35 males and 35 females were taken. Ethical clearance was obtained from the University Ethical Clearance Committee (Protocol number: 2019/135). The study was conducted over a period of 6 months from May 2019 to October 2019. Seventy patients were serially recruited to assess the stigma using the Substance Use Stigma Mechanisms Scale (SU-SMS). It is a twin-center, cross-sectional study, conducted at the Department of Psychiatry, Yenepoya Medical College, Mangalore, and Abyudaya Center for Humanity and Rural Development Integrated Rehabilitation Center for Addiction, Tumkur, India. The sample size was calculated using internalized stigma (R2 = 0.637) with α % level of significance of 0.01 ≥1% and power at 80%. The estimated sample size was 70, in which 35 males and 35 females were taken. Ethical clearance was obtained from the University Ethical Clearance Committee (Protocol number: 2019/135). The study was conducted over a period of 6 months from May 2019 to October 2019. Seventy patients were serially recruited to assess the stigma using the Substance Use Stigma Mechanisms Scale (SU-SMS), [Table 1]. Written informed consent was obtained from all the participants. The study had outpatients or inpatients who were above 18 years of age and diagnosed with alcohol dependence as per the ICD-10 criteria, at least 1-month abstinence from alcohol at the time of interview and without any comorbid psychiatric illness except nicotine dependence. Patients with a history of head injury, epilepsy, diagnosed neurological conditions, and sensory impairments which impair in study participation and patients who are having subnormal intelligence clinically were excluded.
Table 1: Sociodemographic data

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Assessment tools

1. SU-SMS-Stigma assessment using a SU-SMS, by Smith et al.,[21] a measure based on the stigma framework, across two samples with diverse histories of substance use behaviors and treatment histories.

Specifically, the SU-SMS is structured to measure enacted, anticipated, and internalized substance use stigma as distinct constructs and provide subscales reflecting enacted and anticipated stigmas from relevant stigma sources commonly identified in the extant literature (i.e., family members and health-care workers).[21]

The SU-SMS may be administered to substance-using populations more broadly, including those who are out of treatment, nontreatment seeking, treatment seeking, and in treatment for SUD.

All responses are given on a 5-point Likert-type scale, with higher scores indicating greater endorsement of substance use stigma. It has enacted stigma (6 items), anticipated stigma (6 items), and internalized stigma (6 items).

Stigma source subscales can be created for enacted and anticipated stigmas by taking the average responses given for the health-care worker (3 items) and family member (3 items), respectively.

2. A specially designed sociodemographic questionnaire for collecting sociodemographic details.

Data analysis was conducted using the Statistical Package for Social Sciences version 18. (IBM Corporation, New York, USA).


  Results Top


The mean age and standard deviation of males were 39.14 years and 12.99 compared to females which were 41.00 years and 10.72 with P = 0.517, which was not significant. The mean score for enacted stigma of males was found to be 2.45 with a standard deviation of 0.61 and for females 2.15 with a standard deviation of 0.64. The two independent sample t-tests confirm that there is no statistically significant difference in mean score (P = 0.051) between males and females at 5% level of significance, which explains no significant difference seen between males and females for enacted stigma which reflects personal experiences of stereotyping, prejudice, and/or discrimination from others in the past or present due to one's stigmatized attribute.

The mean score for anticipated stigma of males was found to be 1.91 with a standard deviation of 0.47 and for females 2.30 with a standard deviation of 0.78. The two independent sample t-tests confirm that there is a statistically significant difference in mean score (P = 0.015) between males and females at 5% level of significance, which explains that females are having more anticipated stigma as compared to males that reflects expectations of stereotyping, prejudice, and/or discrimination from others in the future due to one's stigmatized attributes.

The mean score for internalized stigma of males was found to be 3.48 with a standard deviation of 0.60 and for females 2.30 with a standard deviation of 0.90. The two independent sample t-tests confirm that there is a statistically significant difference in mean score (P = 0.000) between males and females at 5% level of significance, explaining that males are having more internalized stigma as compared to females seen as the endorsement and application of negative feelings and beliefs about people with SUDs to oneself. The two independent sample t-tests confirm that there is a statically significant difference between males and females with anticipated stigma (mean score [P = 0.015]) and internalized stigma (mean score [P = 0.000]) but not with enacted stigma with mean score (P = 0.051) at 5% level of significance [Table 2].
Table 2: Comparison of stigma

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The two independent sample t-tests confirm that there is a statically significant difference between males and females with anticipated stigma (mean score [P = 0.015]) and internalized stigma (mean score [P = 0.000]) but not with enacted stigma with mean score (P = 0.051) at 5% level of significance.


  Discussion Top


This study shows that females have more anticipated stigma which may affect treatment seeking as compared to males in the society. This anticipated stigma is a result of their own past experiences. They may also have anticipated stigma as a result of observing the experiences of others and/or being aware of societal stigma toward people with SUDs. It is not uncommon, in fact, to find greater associations between enacted and anticipated stigmas with cross-sectional studies. We hypothesize that this represents the contextual complexity of these processes (vs. internalized stigma) and can examine aspects in which past experiences with enacted stigma can raise assumptions for similar events that occur in the future. We would also assume that given these reported associations, enacted and anticipated stigmas could have different health and well-being consequences on people with SUDs (e.g., ability to seek drug use treatment/safer injecting procedures [anticipated stigma] vs. sustained treatment success HIV/HIV/hepatitis C status [enacted stigma]).

We can consider that discriminating between origins of stigma helps to recognize a more nuanced understanding of how and from whom stigma poses an obstacle to receiving these facilities (anticipated stigma from provider) versus achieving optimal care and health outcomes (enacted stigma from family).[24] Substance use stigma is a recognized and common obstacle to improving health inequities within communities impacted by drugs.[24]

In a report by Yang et al. 2013., it was concluded that stigma restricts the ability of people with SUD to seek treatment. Public education that reduces stigma and provides information about treatment is needed. Our study further established gender difference in stigma.[1] Another study by Sarkar et al., 2019, concluded that the experience of internalized stigma and dissatisfaction with quality of life is quite high among people suffering with SUD in India. These results emphasize the need for interventions to reduce the internal perception of stigma and improve the quality of life of individuals with SUD.[25] Persons with alcohol dependence experience stigma, and we found that the gender difference is seen. Stigma associated with substance use is considered a significant barrier to detection and treatment efforts. Results suggest that anticipated stigma is more in females compared to males, which affects treatment seeking; internalized stigma is more in males compared to females. They are forced to confront the negative beliefs and feelings to oneself, leads to devaluing and discrediting of oneself, due to one's substance use status. Enacted stigma did not show a significant difference in our study [Figure 1]. Our study found that males have more internalized stigma compared to females which we need to address.
Figure 1: Comparison of three stigmas

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Limitations

Strengths of the research involve taking samples from two centers in the state of Karnataka, investigating different forms of stigma in alcohol dependenc, including urban, rural and semi-rural genders, taking both outpatients and inpatients, using validated and translated structured questionnaires. The limitations of the study are its cross-sectional design, the hospital sample, the relatively low sample size, and the research did not reflect the experience of younger people with active SUD.

Conclusion

Persons with alcohol dependence experience stigma, and we found that the gender difference is seen. Stigma associated with substance use is considered a significant barrier to detection and treatment efforts. Results suggest that anticipated stigma is more in females compared to males, which affects treatment seeking; internalized stigma is more in males compared to females. They are forced to face negative attitudes and emotions towards themselves, leading to self-devaluation and self-disabling due to the one's drug use status. Enacted stigma did not show a significant difference in our study. Understanding various aspects of stigma will help in providing better management.

Financial support

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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