Qualitative Study to Assess the Attitudes and Perception of Employers Towards Employees with Alcohol Use Disorder (AUD): Evidence from an Emerging Economy

The disease addiction to chemical substances or drugs such as alcohol (ethanol, C 2 H 5 OH) is still not recognised by many medical practitioners as a diagnostic nosology in Ghana. It is usually considered a moral challenge, rather than a medical condition. This perception is propagated even in the Ministry of Health’s Occupational Health and Safety (OHS) policy document which punishes symptoms of substance use disorders. This study seeks to explore the perception and attitude of employers towards employees with alcohol use disorders (AUDs). Method A qualitative approach of in-depth interviews and observations which described the perceived attitudes of employers (using HR managers as proxy) towards employees with AUD of ten private and public hospitals in the Greater-Accra Metropolis was adopted. The face-to face interviews conducted using a an interview guide were audio-recorded and later transcribed. On average, the interview lasted between 45 and 60 minutes. Findings from the 10 interviews revealed that psychological factors accounted for AUD regardless of the nature of their work. In spite of prevalence of AUD in some hospitals, it was interesting to know that majority of these facilities had no employee assistance programmes (EAPs) and the few that had some policies on AUD were not implementing them. This paper focused on some aspect of HR managers’ perceived attitude toward an aspect of their mental well-being which is AUD. However, there are other pertinent issues that are crucial to employee total well-being that can be addressed in future research.


Introduction
Majority of adults are in the workforce and with the increasing workload, employees do not have much choice than to spend a substantial proportion of their time at their places of work (Anderson, 2012).
Studies have reported a strong association between stress at the workplace and elevated levels of alcohol consumption (Chopko, Palmieri & Adams 2013). Alcohol, especially heavy drinking, represents a serious challenge for a number of work sectors and occupations (Anderson, 2012;Corral, Duran & Isusi, 2012). According to Gore, Bloem, Patton, Ferguson, Joseph et al., (2011) heavy drinking is more common in younger employees than older ones, and more among male than female employees. This has been recognized to have a major health risk in terms of disability and enormous effect on work productivity (Porter & Kramer, 2011; WHO, 2018).
Alcohol abuse has adverse effects such as absenteeism, presenteeism, work accidents and injury, turnover intentions, work squabbles and sleeping on the job (Fox et al., 2012). These issues have been of great concern to a number of employers. Employees with heavy drinking habits are challenged in a number of ways especially at their workplace even when they have not drunk that day as the effects of alcohol, such as hangover can last up to 24 hours (Medical News Today, 2018). While heavy drinkers may be quali ed employees with expertise, they may just be present at work but unable to work to expectation, a common cause of presenteeism (Deitchler & Dilger, 2018). Stigmatisation, isolation and rejection are some forms of emotional struggle that employees with AUD face at their workplace (Bauld et al., 2010;Hoare & Flatley, 2008). This means in addition to " ghting" their disease addiction, they also ght stigma, isolation and rejection which increase their stress levels and decrease their productivity (Anderson, 2012;Brener et al., 2011).
These stigmatizing attitudes result in discrimination at the workplace, such as the unfair denial of employment opportunities, as well as restricted access to services, health insurance and housing (Thornicroft et al., 2013). Mostly, employees are unable to discuss their drinking habits with their employers for fear of being discriminated against (Gleeson, 2010;Stuart, 2006). However, if the employer perceives that an employee is exhibiting such tendencies, it is required that the person discloses his status irrespective of the outcome. Based on this, clinical practitioners and researchers are of the opinion that employers are in a powerful position to stamp out stigma tied to AUD in their organisations (McAlpine & Wainer, 2002). Instead, some employers are of the view that such individuals are inept, need extreme supervision, lack understanding and enthusiasm for work, are violent, erratic, are unable to meet Even though most organisations have work policies and legislations for workers with heavy drinking habits, a few studies have shown that employees with such habits for instance face signi cant barriers in their place of work. This is because most employers are unaware and lack understanding of what constitutes alcohol or substance use disorder. Shanker, Liu, Nicholas, Warren, Lai et al., (2014) reported that even after weeks, months and sometimes years when employees have gone off drinking they are perceived to have an aberrant behaviour, weak, lazy or unproductive. Employees with drinking habits are socially marginalised and have to cope with negative comments from workmates and consequently made to return to positions of reduced responsibility (Shankar et al., 2014;Stuart, 2006). A growing number of research have shown that employers are more likely to dismiss employees when they nd out they are addicted to alcohol, especially in cases where their status was not disclosed during the hiring process (Kulka & Bond, 2012) and the tendency of such employees being dismissed when there is a downsizing is high (Quinlan, 2007).
Although the workplace is a great source of distress to many employees, research has shown that the workplace offers many bene ts as a setting for the prevention of AUD (Anderson, 2012). Workplace can be an important and effective place to address AUD by establishing or promoting programs or policies (Webb et al., 2009). A few organisations with such challenges have developed policies to take action (Hermanson et al., 2010). There have been organizational interventions to identify and manage drug problems among employees. The most common is the Employee Assistance Programs (EAPs). EAP has been used as a strategy to enhance functioning, loyalty and performance in organisations around the world (Romzek, LeRoux & Blackmar, 2012). It also encourages and supports treatment of employees with drinking and other behavioural problems.
This policy is known to assist employers by reducing the negative impact of AUD at the workplace, while reducing organisational cost and improve productivity. AUD treatment also improves an individual's functioning leading to increased productivity at work and maximize recovery (Lerman et al., 2012). Through EAPs, employers are trained on how to manage employees with drinking habits with evidence and describe what will be required to bring job performance to an ultimate level (Sonnensthul & Trice, 2018).
The use of alcohol in Ghana is strongly linked to customary and cultural practices (WHO, 2004). In recent times, there have been records of increasing alcohol use among the youth, women and children in particular (Agob, 2016). The economic bene ts of alcohol production cannot be underestimated.
Alcoholic factories make large sums of money from production, marketing and sales of alcohol in this part of the world (Hill, 2008). With the in ux of western cultures, alcoholic beverages from western countries have become readily available for both the young and old, male and female and even at the workplace on commercial basis (Dumbili, 2013). The workplace is somehow increasingly becoming a risk factor for AUD (Anderson, 2012). While personal factors can act as a contributing factor to this menace, organizational causes are equally responsible for workers alcohol use (Shain & Kramer, 2004).
In Ghana, organizational factors such as work structure, work culture and psychosocial constraints have been raised as motivators to alcohol use at the workplace (Akyeampong, 2001). In a study by Shain and Kramer (2004), it was shown that employees who were exposed to alcohol were at higher risk of absenting from work and were less e cient in carrying out responsibilities. In a similar study Bennett and colleagues (2004) reported that the presence of alcohol at the workplace has a causal relationship with job stress and job withdrawal, health problems and it affects productivity. The workplace can contribute positively to a person's mental health or may worsen an existing problem, and or may lead to decline of a person's mental wellbeing. Organizational as well as personal factors contribute to alcohol use disorders in some employees (Shain & Kramer, 2004).
The failure to prevent, recognize and treat drinking problems in the workplace is said to affect employees' productivity. Only a small proportion of people with alcohol problems are hired or allowed to work when they disclose their challenge to their employers (Tse, 2004). In recent times there have been a growing number of educational programs, training workshops and even online resources that aim to change perception and attitudes about employers towards their staff with alcohol use problems (Catalano et al., 2012). Notable among these plans is the creation of employment assistance programs (EAPs) to address and provide assistance to such employees. In spite of all these efforts by mental health professionals to sensitize employers and with the introduction of EAPs in some organisaitons there have been reports of prejudice, stereotypes and discrimination against heavy drinkers in organisations. There have been little alteration in how employers perceive staff with such problems, even in originations with these programs (Quinlan, 2010;Tse, 2004).
Similarly, there has been little changes in employer's attitude toward employing and accepting staff with alcohol use disorder (AUD). Research evidence has shown that human resource managers of small-andmedium sized organizations are reluctant in taking on staff with mental illness as they do not have the needed resources such as a department of human resource management, trained professionals (EAPs) to handle the mental health needs of staff (Shankar et al., 2014). Some employers have argued that they do not hire such persons because they do not have time dedicated to support staff who are unable to meet targets because of their problems (Shankar et al., 2014). A number of employers lack access to their employees mental wellbeing, do not have policies and legislations or support systems in their workplace to address the needs of staff with drinking problems. As noted by many employers, stereotypes, prejudice and discrimination towards alcohol addiction remain a major challenge at work. Yet, most employers are less concerned about the mental well-being of their staff, they are only preoccupied with the numbers (pro t maximization). Despite the evidence of the negative impact of alcohol on workplace performance, surprisingly there are a few studies that have looked at perception and attitudes of employers towards employees with alcohol use disorders. Similarly, in most organisations there are no clear cut policies and rules on implementation and preventive strategies to reduce the harm caused by alcohol. Even where there are policies, such as Ghana Health Service, it tends to be punitive and not corrective or preventive hence the need for this study (MOH, 2010). The study, among other things seek explores the perception and attitude of employers toward employees with alcohol use disorder (AUD), as well as examines the effectives of the implementation of EAPs in organisations.

Research Methodology
Ten human resources (HR) managers, 5 from private for-pro t hospitals (labelled R1 -R5) and 5 from government not-for-pro t hospitals (labelled S1-S5) were purposively sampled and interviewed. For private hospitals, we selected those that have operated for at least 10 years in Greater Accra region of Ghana and had not less than 100 employees. The government hospitals had to have been in operation for not less than 5 years as a hospital or polyclinic and had not less than 200 employees. Government hospitals in Ghana generally employ far more employees and professionals per patient load than private hospitals.
Of the ten human resources managers interviewed 7 were males and 3 were females, aged between 30 and 49 years except for one in a private hospital who was more than 60 years. The interviews were conducted in the o ces of the participant's workplace with the help of two research assistants who were acquainted with the content of the study guide. Prior to this, institutional entry was sought from the research departments of the various institutions selected for this study after approval by University of Ghana Business School Ethical Committee. The interview was conducted face-to-face using an interview guide, which included open-ended questions. The structure of the guide helped the researchers to observe the participants and the conversations were also audio-taped after seeking the consent of the participants.
On average, the interview lasted between 45 minutes to an hour. Extensive notes were taken during the interviews, and summaries of each interview were written right after the interview. The names of the research participants were left out to ensure con dentiality and anonymity. At the end of the data collection all the transcripts were coded and transcribed independently by each researcher and cross validated. To ensure content validity, summaries of the transcripts were sent to the participants to ensure that the exact meanings of their perceived attitude had been captured. Subsequently, thematic content analyses was done to generate results and to derive meanings which have been discussed in the following sections.

Analysis and Discussion of Findings
This aspect of the study examines the prevalence of alcohol use disorder (AUD), factors that contribute to AUD at the workplace and employee's perception of employee assistance program (EAPs). This information set a tone for a good understanding of AUD at the workplace.

A. Prevalence of AUD
Alcohol use disorder is a common condition among the working class and could be in excess of one per every 10 employees as prevalence in the general community was estimated to be 12.7% in the general US community using DSM IV (Grant et al 2017). Relatively, higher percentage than the general population is expected among the working class because AUD is a developmental disorder (Roerecke & Rehm, 2014) beginning in the teens and generally take some 10 years lag behind onset of use to exhibit symptoms Due to the low knowledge of AUD as a medical condition (Maisto, Kirouac & Witkiewitz, 2014) many people tend to see it as a moral problem and will not easily disclose the existence of persons known to them with the condition. Most of the HR managers interviewed (70%) denied knowledge of employees with AUD. Some explained they could not tell while others claim it could not be ascertained even though they work in hospitals where this diagnosis is made.
I have not seen any staff drunk before. I wouldn't actually know what constitutes it. Because of the nature of the work if anybody even takes alcohol it will be after close of work when everybody is at home, therefore it will be di cult for me to tell. On duty. R1 Now, as I am aware, I don't know any of my employees with such a disorder. R2 However, the few who admitted that theIR staff had the condition even attempted to explain it away that such employees were either working at a very low level and so did not in uence the work or that they were only temporary workers. Others did not really know the difference between regular use of alcohol and the person with AUD and may be oblivious to the fact that such persons can be counterproductive. Another considered AUD to be only when the person is seen to be intoxicated with alcohol during the day, even though the alcohol withdrawal, which can manifest 12 hours after the last drink and last up to 72 hours, possibly from the previous night can become a medical emergency (Roffman, & Stern, 2006). In fact, studies show that persons who regularly drink excess alcohol tend to be more argumentative and prone to injuries at work. (Rehm, 2011) So far, we know of three and it could be irregular. Irregular in the sense that you don't see them every day, but most times when you see them, they are drunk. So, it is irregular. R1 Currently, I cannot pick on one, but about 8 years ago we used to have one man at the records who was an alcoholic and it affected his performance. But the people we have now have not shown any great level of that effect on them, on their performance. Probably they may go and booze, but in the morning they will come to work okay. So, when we talk about alcoholics, I do not think we have any. Myself, I drink Whiskey at home, but I come to work normal. I don't drink to booze. R2 Usually labourers are those seen to be drunk but maybe two to three days. Not all the time. R3 Some employers shared: Usually before work, but the effects will still be on during working periods. I see them in the afternoons or in the morning working day because I don't come to work on weekends and night. R1 Not really because they seem to reek of alcohol sometimes but you can't perceive whether they drank it before coming to work or it was something that they drank yesterday before coming to work because they are casual workers so we don't really know. R2 This shows how persons with AUD at the workplace are not considered to have serious ill-health like diabetes and hypertension, which require their employers to provide the necessary help to optimize productivity (Sturm, 2002).

B. Factors In uencing Workplace AUD
The study found that the participants attributed factors in uencing AUD to be biological, environmental, social and psychological.

i. Biological Factors
Some of the HR managers believed that AUD could be heritable and this is in sync with the disease model of addiction (Bevilacqua & Goldman, 2009). Thus, people are born with a higher propensity to become addicts and the substance they get addicted to is only a symptom of their condition (Spooner & Hetherington, 2004). According to them, this repetitive behaviour picked up from their family line or genes that have been passed on through generations make them more vulnerable to developing alcoholism. One respondent claimed: I think that some people were born with this urge to drink. When you look at their family there you will realize that most of them drink. This urge tends to increase when they are surrounded by people who drink then it becomes a habit. R1 This supports the results of Reilly, Noronha, Goldman and Koob (2017) who examined genetic studies of alcohol dependence in the context of the addiction cycle. Speci cally, the family, twin and adoption studies demonstrate clearly that alcohol dependence and alcohol use disorders are phenotypically complex and heritable which is estimated at approximately 50-60% of the total phenotypic variability.
Also the study showed that the vulnerability to alcohol use disorders can be due to multiple genetic or environmental factors or their interaction which gives rise to extensive and daunting heterogeneity.
ii. Environmental Factors Some participants stated: One of the factors that in uence AUD are the alcohol stores that have been set up almost in every vicinity that people live in. So far as they live close to them they will nd joy in drinking. So I think that it is one factor. If these stores were not there, where would they have gone to? R1 In this hospital, probably I would say, my guys have been going to quarters here, so there's the proximity to the selling point. There's a place they call Chicago. So, whenever you see them coming from that direction, they've gone to take some shots so that's a major factor. several years ago there was even some just at the car park in front of the hospital, they were selling alcohol there, they were stopped so now they have to walk to quarters to top up occasionally and so that's one of the factors. R2 The above statements from respondents indicate that people who live closer to alcohol establishments such as alcohol retail stores are prone to participate in alcoholism. Today media outlets have generated attractive adverts that attract the public. Thus people are induced to try drinking and if they enjoy it, they take no account as to whether their tolerance level to alcohol is high or low. This nding nds supports the Ecological System theory which explains how alcohol use disorder results at the workplace due to an interplay between the work environment and the employee's internal factors. Thereby the kind of constraints and support employees receive from their employers in some way affect their behaviour on and off the job (Gruenewald, Remer, & LaScala, 2014).

iii. Social Factors
With social actors, participants revealed that some people who are prone to alcoholism, are in uenced by the numerous functions they attend especially when served with alcoholic drinks at such functions. In order to t in and be well liked may cause one to participate in activities they normally would have not. If care is not taken, they end up drinking frequently at such events and even start craving for alcohol after every day's work.
Most of the time when programs are organized like parties or there is a funeral, they give you alcohol to drink you cannot say that you will not take it because of your friends. You have to learn to drink it by force. And if you continue you can become addicted to it. R1 Okay most of the people who work at the morgue and collect the refuse they are the most people seen to reek of alcohol but I can't really tell if it's because of those factors that they always drink alcohol. R2

iv. Psychological Factors
Data collected from respondents showed that everyone faces an issue one way or the other. However every person handles issues in their own unique way. As a result people who are usually highly stressed, depressed and with other mental health conditions are more vulnerable to developing alcoholism as alcohol is used by such to suppress their feelings and relief of psychological disorders. Overtime they end up leading to alcohol use disorders. In addition, the study showed that some people may have faced adverse events during childhood which exposed them to the use of alcohol and as they grow they are unable to control their urge leading to alcohol use disorders in adulthood. Some respondents stated: Well for me I think that some people drink a lot when they are facing a problem. They think that drinking will help them to forget about the issue so they nd solace in drinking which can be a serious problem. R1 Some think that when you get boozed you forget the problems you are facing, that's probably why they are drinking, I don't think it's sensible for you to drink and forget problems, you'll never forget the problem. R2 I think that people who went through di cult situations at a tender age start to develop drinking habits early. Since they drink to overcome their fears. And some of these children they were introduced to drinking by negative people and as they grow you realize that they become glued to alcohol use. R3 According to Keyes, Hatzenbuehler and Hasin (2011) many but not all studies have shown that exposure to adverse events in childhood, such as sexual, emotional, and physical abuse, is a risk factor for developing an AUD in adulthood. The study ndings however is consistent with the ndings of Meyers et al. (2015) who sampled Israeli adults with a relatively high prevalence of the ADH1B*2 allele (47 percent either heterozygous or homozygous). A history of childhood adversity moderated the in uence of ADH1B*2 on alcohol-related phenotypes. In addition, there was a stronger effect of ADH1B*2 on AUD severity and the maximum number of drinks consumed in a day in individuals who had a history of childhood adversity compared with those who did not. ) have also shown that persons who start drinking at an early age are more likely to develop addiction later in life. What is not clear however is, whether persons born to have addiction start drinking early or early drinking cause damage to the developing brain, particularly to the frontal lobe that develop fully in the mid-20s as opposed to the pleasure centers found in the medial temporal lobe that is developed in the teenage years (Jacobus & Tapert, 2015). This implies that, while young people derive pleasure or euphoria from the abuse of drugs, they are unable to perceive the long term implications and consequences of their acts on their frontal lobe function.
Further, the study sought to nd out if alcohol use disorders result in presenteeism, absenteeism or impaired productivity. Responses from interviewees outlined that: Sure, sure, the number of times they fall sick affect them. Even if they are not sick the level of their strength becomes compromised, when they come to work so de nitely it affects productivity. R1 Usually these people fall sick easily and absent themselves from work. So someone have to do their work for them. R2 From statements above, the study disclosed that, usually people with such behaviour tend to fall ill often and absent themselves from work as too much of alcohol destroys the immune system. The results of this study is in line with the results of Buvik et al. (2018) in Carollo (2019) who aimed to map the frequency of alcohol related absence and ine ciency using survey data from a broad sample of employees. They also explored how alcohol use, absenteeism and presenteeism are experienced and handled using data from qualitative reviews. Further analyses revealed that alcohol absence and presenteeism result in economic and practical problems. Since most of the managers mentioned that they had to spend huge sums of money and effort on a single case of an employee who had an alcohol use problems.
In addition, this study also demonstrated that employees prone to alcohol usage demonstrated reduced productivity as the effort one may put into work is impeded. Research evidence suggest that alcohol could impair productivity. According to Andersen, Andersen, Olsen, Grønbaek and Strandberg-Larsen (2012) its impact on the accumulation of human capital through work; the time in life when alcohol leads to ill health and premature death; and its signi cance in the working age population, relative to other risk factors, results in impaired health and premature death.

C. Attitude of Employers towards Employees with Alcohol Use Disorders
This section intended to nd out the diverse form of attitude employers exhibit towards employees with AUD. In line with this, the study sought to know the standards these organizations have put in place to implement policies on AUD. Especially whether they have employee assistance program policies to aid employees. Some respondents asserted: In our facility, counselling sessions are held in order to educate and advise us against the use of alcohol. S3 We have a code of conduct which is spelled out clearly and every employee of the hospital is aware of. But sometimes they try to address it through counselling and if that fails then they warn and query them and sometimes even dismissal letters are issued to them. R2 No, we don't have a separate policy for alcohol use disorder, we have a policy code of conduct, full policy it borders on everything and management have been a bit strict on it, ……. verbal warnings and advises, and if you fail to adhere to them, these policies are……… and the punishment thereof given. S2 Responses gathered from participants revealed that these institutions do not have a single set or standalone policy on AUD rather it is embedded in their codes of conduct which is made known to every employee of the organization. Others also made mention of some form of assistance put in place by employers to support employees in the form of counselling programs that help employees cope with stress, mental illness and other related issues. None speci cally mentioned Employee Assistance Programme (EAP) that has been shown to help persons particularly with AUD as asserted by Ames and Bennett's (2011) that some workplace offers many advantages as a setting for preventing alcohol issues among their employees.
Most found the counselling sessions to be very helpful. Others also stressed that their code of conduct included punishments such as dismissal when seen drunk on the work premises during working hours as these can cause damage to the organization. In addition, room is not created to recruit people with alcohol use disorders.
In our institution, as human resource persons we are not allowed to recruit people who have drinking habits or uncontrollably drinking habits as all candidates we aspire to employ go through a physical examination before they are brought on board. We deal with patients not to recruit and treat people we bring on board. However if per chance an employee should exhibit such tendencies after being recruited the severity of the issue will cause the dismissal of the person. R4 The study ndings is similar to Negura and Maranda's (2008) study who sought to examine the social representations underlying managers' behaviour towards the issue of substance misuse in the company or the hiring process. Seventy managers hiring potential workers for medium-and small sized companies in Montreal and Quebec in Canada were sampled for the study. Data from the managers using a semistructured interviews indicated that the managers were less likely to employ people who abuse substance of any form, in that the managers were closed minded and ambivalent towards such people.

Conclusion
Studies have demonstrated that drinking patterns and the prevalence of alcohol-related adverse consequences, including alcohol use disorder (AUD), differ substantially among countries. The study showed a lower rate of alcohol use disorders among employees in health institutions which may be due to denial of the condition or lack of awareness of it. Alcohol use disorders were attributed to biological, environmental, social and psychological factors. To improve productivity and promote employee safety and personal well-being, it is advised that employees of health institutions pursue treatment and rehabilitation for persons with AUD by adopting EAP.

Recommendation
Acknowledgement and acceptance of AUD as a medical condition treatable like other chronic medical conditions is still derisory even among health industry and much education is needed. Employers need to be made aware it is against International Labour Regulations which Ghana is a signatory to punish an employee for a medical condition. Employers can be equipped with EAP policies to manage not only employees with AUD but also, other psychological conditions which have the potential of reducing productivity just as the general medical conditions they disproportionately give more attention.
Organised labour should be approached to demand EAP services as part of employment contract to guarantee job security and improve productivity which will be a gain for both employers and labour. For future studies, a quantitative study that will assess the prevalence of AUD among various sectors of industry will provide a solid basis for adoption of EAP. A longitudinal study comparing productivity in the long term of organisations that manage employees with AUD as opposed to those that adopt a punitive measure will be a good litmus test for adoption of EAP in Ghana. Declarations EKD contributed to conceptualization, writing of the methods, supervision of data and reviewing of the work. LAA helped with conceptualization, methodology, data analysis and editing. TMA helped with reviewing, editing and supervision of the data collection. All authors reviewed the nal version of the manuscript and agreed on it for publication.

Availability of data and materials
The data collected and analyzed during this study are not publicly available due to con dentiality and anonymity reasons. However, de-identi ed transcripts might be available from the corresponding author (EKD) upon reasonable request and with permission from the participating facilities and HR managers.

Con ict of Interest
There is no con ict of interest as manuscript has not been sent in full or in part to any other journal for consideration for publication, hence there is no competing interest Ethics approval and Consent to participate The study procedure was approved rst by the Greater Accra Regional Health Directorate ethics committee and subsequently approved by the research units of the various hospitals. Also a consent form was signed by the research participants.