Social and Family Determinants of Substance Abuse among the Patients of Two Hospitals in Bangladesh

Substance use related disorders are major concerns for Bangladesh due to the increasing burden on family, society and nation. Various family and social factors contribute to the development of these disorders. However, the relevant factors were yet to be explored in the Bangladesh from multiple sites study. This study aimed to attempt find out the Social and Family determinants of substance abuse. It was a cross sectional study where one hundred and one substance users were interviewed from two tertiary level hospitals in the Dhaka. Peer pressure and parental disputes were significant contributing factors for substance dependence and discussion about the adverse effect of the substance abuse in family had protective role. The study findings will help in planning the preventive program substance dependence.


Introduction
Substance Use Disorder is digging a big hole in the social structure of Bangladesh. The term is more commonly known as drug addiction among us. It is one of the major global public health concern and major contributors to the global disease burden [1]. Evidence only revealed the alcohol consumption related problems which caused an estimated 3.8% of all global deaths and 4.6% of global disabilityadjusted life-years [2]. Moreover, drug abuse is suspected to be one of the leading causes of sickness in South Asia by 2020 [3]. Geographically, Bangladesh is an important transit route for international drug trafficking and it made the country vulnerable for drug addiction. A multi-centric community based study in the country revealed that 0.6% of the people met the criteria of drug dependence. However, it is suspected that the actual burden is higher than the reported rate due to sociocultural stigma and legal issues [4].
Multiple biological, psychological and social factors are responsible for Substance Abuse. Irrespective of genetic influence, the social and family factors are important determinants for substance abuse. Family creates a sense of judgment and moral structure for the children and that influence them in the decision making throughout the lives. Among the various social factors, peer and family influence are noteworthy. Peer influence is a major cause of adolescent drug behavior [5]. Another key determinant is inequity of socioeconomic status and discrimination [6]. Unemployment, Social Network Norms, poverty, and betrayal of spouse also contribute to drug abuse. However, in most instances it is a combination of several factors instead of just one [7].
Familial risk factors for substance abuse include childhood maltreatment (including abuse and neglect), parental or familial substance abuse, marital status of parents and level of parental education, parent-child relationships, familial socioeconomic status, and child perception that parents approve their substance use [8]. Moreover, parental attitudes favoring alcohol and other drug use tend to be linked with a greater likelihood of substance use by adolescents [9]. Some prominent family factors of drug addiction are found as family atmosphere, strength of family ties, sense of family happiness, structure of authority in the family, and alcoholism. In families where there is warmth and love, children rarely take drugs [10]. Moreover, depression, peer delinquency, family-violence, victimization, and community-violence witness are significantly related to substance abuse [11]. Peer pressure is consistently implicated in the excessive drinking of alcohol among college students and it is a combination of three distinct influences: overt offers of alcohol, modeling and social norms. Overt offers of alcohol can range from polite gestures to intense goading or command to drink. Modeling occurs when the student's behavior corresponds to another student's concurrent drinking behavior. Perceived social norms can serve to make excessive alcohol use appear common and acceptable to the student [12] and social environment has a profound, but complex influence on drug use [13].
Substance dependence is causing educational drop out, unemployment, financial crisis, psychiatric disorders, family disharmony, domestic violence, criminal activities and many other social disadvantages. However, what are the significant family and social factors influencing the substance use related behavior in Bangladesh, is still inconclusive. The aim of the study was to explore the role of social factors in substance abuse. The findings from the study will help in future planning of Narcotics Control Program of the country and further exploration.

Methodology
This was a cross sectional study conducted in two prime hospitals in Dhaka Bangladesh. The centers were-National Institute of Mental Health (NIMH) which is a leading mental health institution of the country and the second one was "Central Drug Addiction Treatment Centre (CTC)" at Tejgaon, Dhaka-the only government center devoted for treatment of substance abuse disorder. Considering the prevalence of the substance use disorder, patient turnover in these hospitals and funding constrain, local expert researcher's opinion and statistical sampling technique; a sample size more than hundred would be a good representative sample for the study. The inclusion criteria were age 18 years or more and fulfil the criteria of Substance Use Disorder according to DSM IV. However, those who had severe psychotic feature were excluded from the study. To achieve the desired sample, 109 patients were approached. It resulted a sample size of 101 where sixty one respondents were from National Institute of Mental Health and forty respondents were interviewed from Central Drug Addiction Treatment Centre (CTC). Consecutive sampling was done using a predefined semi structure questionnaire for the study. That included socio-demographic variables such as gender, age, educational level, employment status, marital status, monthly family income. Another semi structure questionnaire was developed based on existing sociocultural factors in the literature and experience in Bangladeshi culture. A prior permission was taken from the director of NIMH and CTC, in addition all-official procedure was also maintained. Patient register of in-patient and outpatient department of respective institution were taken as sampling frame. Patients were informed about the purpose of the study and ethical issues. Informed consent was taken from the patients who were willing to give interview and was assured of confidentiality and freedom of choice for participation. After collecting the data, it was checked and rechecked for omissions, inconsistency and improbabilities. After cleaning the data it was edited, coded and entered into the computer. Data analysis was performed by Statistical Package for Social Science (SPSS), versoin-21. The study was approved by the Ethical Review Committee of Bangabandhu Sheikh Mujib Medical University.

Results
About 97% of respondents were male and the age of the ranged from 18 to 56 years (31 with SD 7.68) ( Table 1).
The study revealed that almost 95% of respondents admitted that they witnessed quarrel among the parents and domestic violence frequently in the last year (Table 2).

Social factors
The respondents revealed that cannabis was the most easily available drugs followed by Phensedyl (Cough Syrup containing Chlorpheniramine Maleate and Codeine Phosphate), alcohol, Yaba (a mixture of methamphetamine and caffeine) and heroine. Moreover, most of the participants of the study used cannabis as their first drug of abuse. More than 95% of the respondents admitted that their close friends were substance dependent and most of them were influenced by peers. Social recreation available was available for 70.3% of the respondents. Regarding the leisure activities, television watching (41.6%) and gossiping with friends (31.7%) was found among the respondents. The respondents who gossip with the friends had a higher rate of cannabis and Yaba use. However, it was not statistically significant. Fifty six percent of their friends were involved in antisocial behavior. However, 33.7% of the respondent had forensic history. Use of cannabis was more common among the respondents from a family with lower income and Yaba was more commonly used by the person with higher economic status. However, economic status of the family and the type of substance use was not statistically significant.  Table 1: Socio-demographic characteristics of the respondents.
Majority of respondents agreed that they got help from their parents when they were in trouble. Moreover, the respondents who took polysubtance faced more forensic problem than single substance abuser. The study revealed a significant relationship (p=0.001) between the substance dependency and quarrel between parents within last year. Another finding is that the open discussion between parents or among family members about substance dependency act as protective factors to the respondents, (p=0.024).

Discussion
This is one of the first studies in multiple hospitals to find out the family and social factors of substance abuse in Bangladesh that can help to make future planning. The study revealed about 73% of the respondents were poly-substance dependent. Peer pressure of risk taking behavior and quarrel between the parents significantly increased the risk of polysubstsance abuse. Younger, unemployed people with significant childhood emotional and physical neglect usually become polysubstance dependent [14]. The importance of social and family factors were also documented in the studies of [15,16].
The study revealed that more than 90% of the respondents were brought to the center against their will. Most of the respondents were from urban area and married; businessmen were more frequent as they had good family support to take the initiative. We had only three female respondents as substance dependent. It may be due to caregivers' rigidity to admit that their daughter takes drug and they are reluctant to seek treatment. According to United Nation survey about 13% female in Bangladesh were substance depended and their number of female substance user is increasing [17].
The lack of any discussion with parents or other family members about substance abuse emerged as an significant risk factor as majority of the respondents (86.1%) informed that they never discussed with their family about this issue. Moreover, about fifty percent of the respondents admitted that their family member used to take various substances. Parental support reduce the risk of substance dependence approximately 50% and the use of substance by the family member increase the risk [16,[18][19][20].