Family and Stigmatization: Coping Experience of Persons with Substance Use Disorders in North Central Nigeria

In northern Nigeria, stigma has been used as a means of discouraging drug use because of the claim that substance users are responsible for their choices, in this line many families also adopted the same measure as a way of chastising family members involved in drug use. This qualitative study on stigma investigated the personal experiences of 40 people with a history of drug use who are receiving treatment in a facility. The study used a purposive sampling technique to obtain information from participants through interviews. Statistically, this study also obtained data from 261 participants admitted to the same facility over 7 years ago. From this population, 59.4% were diagnosed with Substance Use Disorder (SUD), while 3.8% were diagnosed with Substance Use Disorder comorbid mental illness. Compare to females, there were more males at 85.1%. Furthermore, 55.0% are between the ages of 16 to 30 years of age, making it the highest age group that participated in the study. On marital status singles made up the highest number at 86.4%, participants raised by a single parent were 2 which is .9%. Based on family type, the mean obtained was 1.18 and SD of .387 these participants were grouped into a monogamous and polygamous family. Two hypotheses raised in this study predicted that “there is likelihood that person with substance use disorder will have a stigmatized experience” and “Persons with substance use disorder will have ways to cope with stigmatization” were tested to be significant, the Nvivo software was used in analysing the data obtained from the interviews. The outcome of the study suggests that family members are often the first point of stigmatization for drug-using persons in most families in North-central Nigeria.


Introduction
The word stigma is described as differences shown to a person or others for peculiar reasons that are often related to their nature, physical, social or psychological health status, life choices and lifestyle.According to Byrne (2000), stigma connotes a disgrace or stain that brings separation between people to the open [1].Power has been the connecting string for stigmatising the stigmatised [2].In mental health, addiction is referred to as Substance Use Disorder [3].Individuals with Substance Use Disorder (SUD) often experience more derogatory comments from others.Opinions from different countries suggest that SUDs are more at risk for stigmatization [4], because their behaviour may be seen as self-damaging [4].More times than not, their families are blamed, disgraced or stigmatized [5], considering that SUDs should have power over the impulse of substance use.Sanden et al (2014) added that, with stigma, all family members are affected directly or indirectly [6].More 96 so, children from families of SUD are exposed to the risk of using early [7], which is why Parental negligence is often linked to problems associated with SUD, these have led to self-blame, hence, accepting to share in the shame of stigma with SUDs' who are members of the family [8,9,10].What determines the self-blame or selfstigma of parents is decided by people closely observing who are related to these parents [8,9,10].People who experience stigma over time develop a poor impression about who they are because they have registered in their minds these stereotypes by others [11,12,13] and how it has affected the reputation of other family members [14,15].Substance Abuse and Mental Health Service Administration reported that stigma has been the culprit for poor treatment-seeking behaviour for almost 50% to 60% of people with psychological problems.However, the shame connected to stigma is minimized when people open up about their conditions [16,17].Studies have shown that the rate of drug use among Nigerians who are 15 to 64 years of age stood at 14.4% 1n 2018 compared to 5.5% recorded globally.Among the 3 million people reported with SUD, most of them had issues related to the family of which poor attention to children is one among many others [18].According to Holubova, et al, the ability to cope with stigma experience was common among people challenged with mental health issues [19].Maryam et al also found a relationship between stigma and coping mechanisms [15].

Significance of the Study
This study will be valuable to stakeholders in substance abuse management to educate family members on best ways to relate with persons with substance use disorder in the family.The study will also be useful to policymakers in enacting laws that would take care of family stigma towards persons with substance use disorder.The outcome of this study will contribute to knowledge in public health to correct the perception regarding people with substance use disorder and the relationship of stigma on substance use.

Research Gap
This research will cover the paucity of studies on how SUDs cope with their experience of stigma.It will contribute to knowledge on healthy coping style and new therapeutic approach in handling stigma.

Aim and Objectives
This study aim to explore the experience of people who have suffered stigmatization as a result of using substances and the methods they adopted in coping.The following are the specific objectives of the study: • To understand the experience of stigmatization by persons with substance use disorder within the family.

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To explore the ways persons with substance use disorder cope with stigmatization.

Research Questions
The research will attempt to answer the following questions: • What was the stigmatization experience of substances use disorder individuals within family?• What are the ways persons with substance use disorder cope with stigmatization?
There is likelihood that person with substance use disorder will have a stigmatized experience.

•
Persons with substance use disorder will have ways to cope with stigmatization.

Methodology Research Design
The study adopted a qualitative design method to investigate the phenomenon under review.This study aims to explore the involvement of family members in the stigmatization of SUDs and the coping methods employed by the stigmatised.

Scope of the Study
This study explore the experience of stigma by persons with substance use disorder from family members.The research is a qualitative study and involve participants 18 and above, the study covered four different substance abuse treatment facilities within northcentral Nigeria recognized and approved by the ministry of health, Nigeria.

Population
The participants of this study are selected from a rehabilitation centre in north-central Nigeria with an interest in SUDs, the participants are between 18 years and above comprising of all sex.Sample A total of 40 participants admitted to a rehabilitation centre and diagnosed with substance use disorder were interviewed to understand their personal experience with stigma.Four out of the authors interviewed 10 participants each separately.

Recruitment Process
Participants were contacted from a drug treatment facility in north central Nigeria.What determines their participation is a proven knowledge of the concept 'stigma' and previous involvement with substance use.

Sampling Technique
The researchers used a purposive sampling technique for selecting participants for the study.These participants willingly gave in-depth information on the phenomenon being studied, they are recruited from rehabilitation centres in north-central Nigeria.The inclusion criteria are: Participants have not used any psychoactive substance at the time of the interview or mood-altering medication.

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The participants are not experiencing withdrawal symptoms from substance used.

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Participants' mode of admission is voluntary.

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• Only participants with a history of experiencing stigma are included.

Exclusion criteria •
Participants admitted for substance use with comorbid mental illness were not included.

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Participants who don't understand the concept of the study 'stigma.' • Mentally unstable participants.

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Participants with poor knowledge of the negative effects of substance abuse

Instruments
The following items will be utilized for the study; 1.
An audio recorder.

2.
A journal/diary (paper) and pencil for noting non-verbal cues during interviews.

3.
A printed copy of the interview guide.

Ethical Clearance
The researchers obtained permission from the research ethical committee of the Centre for Addiction Treatment and Research Vom.

Procedure for Data Collection
The researchers used structured interviews for collecting data from participants.A total of 40 persons diagnosed with substance use disorder volunteered to be interviewed, it lasted for a period of 30 to 50 minutes, 36 males and 4 females.The aim is to understand the phenomenon of family stigma among this population.The interview session was carried out by 4 of the authors, each of whom interviewed 10 participants.The information was transcribed separately by the authors which was later exchanged between the authors and re-transcribed before it was coded and analysed using Nvivo software.The researchers pre-informed the participants on what the study seek to achieve, reviewed some of the questions with them to make them relaxed, explain the aim and appreciate them for indicating to volunteer information.

Method of Data Analysis
The data was collected using an audio-recording device which was later transcribed by each of the interviewers.The interpretation was later transferred to other authors to double-read and be sure there are no discrepancies and ensure that some level of accuracy is achieved.The interpretation was then coded for analysis using Nvivo software.

Result
Table

Stigma from Family Members
Findings revealed that the various ways that participants experienced stigma from family members include exclusion from decision-making, being ignored, and refusal of assistance.

Exclusion from Decision Making
Results from common statements showed that family members stigmatize participants by excluding them from the decision-making process in the family.Some of the Statements such as: "In the family there are certain decisions that if they want to take, my inputs are not completely acceptable" and statements such as "…then in family they want to salient me because I do substance"

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further indicated that participants are not allowed to contribute to decision making within the family.

Being ignored
Results from the interview showed that ignoring participants was another means of stigmatization experienced by participants in the family.Common statements as: "Even if I should talk about something very important to the family, they will not listen so I do things on my own" and "At a point they stopped talking to me, they were not giving me attention again because of my smoking attitude, so at a point I had that stigma period in my family" all points to this fact.This usually leads to a point where participants and family members are not on talking terms.The statement: "my brothers we are not in talking terms with them because of the problem my substance use has caused" succinctly explicates the point of feeling ignored.

Refused of assistance
Common responses showed that participants felt stigmatized by family members by being refused financial assistance, as indicated by the statement: "When I was admitted in school, I visited my uncle, he knew I was into substance and refuse giving me money when am to leave back to school" and also, common statements such as "They believe other ones even my younger ones more than me, she prefers to invest in my younger ones than me because I take substance, that's a stigma to me" points to family members' refusal to assist participants.

Means of Coping with Stigmatization
The findings revealed that as a coping strategy for stigmatization, respondents engaged in more substance abuse, indifference, avoidance of people, and reduce interactions.

Substance Abuse
Results revealed that common responses indicated that being stigmatized for substance abuse, participants resulted to using more substances to calm down and provide some form of relief for themselves as a means of coping with the stigmatization.Some common statements such as "Yes, sometimes when am stigmatized I will go and use substance as a way of calming myself down" and "Stigmatization makes people to continue doing what they are doing most especially substance has a way of giving relief" explain more.Indifference Common statements such as: "…you just feel why don't I just take the substance since everybody has already looked at me in that light" point to participants resulting in indifference to people regarding their substance abuse.

Avoidance of People
Results indicated that participants avoid other people that are not substance users so as not to be stigmatized.This is shown by statements such as: "I don't like to let them know what am doing and sometimes I normally go out in the evenings just to avoid being stigmatized that I smoke" and "I don't do it where people are, I hide and do it.I feel that's a stigma to me".Furthermore, common statements such as: "I avoid going to places that I will be stigmatized most especially in a gathering of my mate, I don't go there because I don't want to be stigmatized.It helps me to reduce, to avoid stigma" points to this fact.

Reduced Interactions
Findings showed that participants engaged in fewer interactions with other people to cope with stigmatization.This is shown by the following statements: "Because most people in my area their eyes are open, they normally see that I smoke so I try to reduce the outing I go" and "…then it goes to a time that anytime my siblings are going out I will not like to hang out with them because of that fear, I choose not to" Most participants feel the need not to interact with people as a reaction to stigmatization.

Discussion
The research focused on identifying the experience of stigmatization among persons with substance use disorders and the role of family members.The target participants were people admitted to a treatment facility in north central Nigeria.The participants comprised people of different ages, sex, family type and marital status.The research utilized data from 261 people admitted to the facility from 2014 to 2021, the emerging themes from this research revealed the various ways that persons with SUD experienced stigma from family members, this includes exclusion from decision-making, being ignored, and refusal of assistance.This result is in line with earlier predictions made.

Exclusion from Decision Making
Families deprive persons with substance use disorder of taking decisions that concerns their collective interest.Interviews with participants suggest that SUDs feel stigmatized when important family decisions are taken without them, by way of attributing it to their drug use.Link et al, pointed out that, "Avoidance and social distance means that the stigmatized are often excluded from useful social interactions [20]."In this interview, Participants reported that; 99 "In the family, there are certain decisions that if they want to take, my inputs are not completely acceptable…they want to salient me because I do substance"

Being ignored
The study also revealed that substance users from families suffer disregard because of their drug consumption.Some of the participants interviewed expressed their experiences.
"At a point they stopped talking to me, they were not giving me attention again because of my smoking attitude, so at a point, I had that stigma period in my family" This usually leads to a point where participants and family members are not talking about terms "my brothers we are not in talking terms with them because of the problem my substance use has caused" Refused of assistance The family has often denied helping SUDs considering that they are robbing the family of its dignity and financing their substance use with family income.Most times families perceive that not giving money or any valuable property will minimize SUDs' chances of selling it to finance substance use, however, most often this extends to moral and social support.
"When I was admitted in school, I visited my uncle, he knew I was into substance and refuse giving me money when am to leave back to school" "They believe other ones, even my younger ones more than me, she prefers to invest in my younger ones than me because I take substance, that's a stigma to me" Coping with stigmatization Coping with stigmatization can be challenging for people with SUD.In north-central Nigeria where substance abuse is perceived as moral failure has been most difficult for SUDs, this has often resulted in regrettable outcomes like using the substance as a defence mechanism.The researchers predicted that Persons with substance use disorder will have ways to cope with stigmatization was proven to be significant following the responses from the participants interviewed.

Substance Abuse
The findings revealed that as means of coping with stigmatization, respondents engaged in more substance abuse, indifference, avoidance of people, and reduce interactions.During interviews with participants, their responses suggest an increase in substance use following the experience of stigma "Yes, sometimes when am stigmatized I will go and use substance as a way of calming myself down" "Stigmatization makes people to continue doing what they are doing most especially substance has a way of giving relief" In a study by Maryam et al, they pointed out that, people who experienced stigma developed coping mechanisms and There is a relationship between Coping and stigma [14,19].David, et al added that Substance using persons reported that members of their families discredited them and seized from giving them all assistance they previously enjoyed [21].Over time, they developed poor self-esteem and self-worth, and the harsh criticism they suffered interfered with their resilience level.Emotional and social support is pivotal in substance use cessation.Indifference Some of the participants feel indifferent to family members who stigmatize them.According to participants during the interview, they are indifferent to stigmatisation thereby worsening substance intake.
"…you just feel why don't I just take the substance since everybody has already looked at me in that light" The responses from participants suggest that stigmatizing substance users only worsen the intake.

Avoidance of People
In some instances, persons with SUDs keep their distance from non-users to survive stigmatization from family members thereby increasing the use of substances.The interview with participants implied that SUDs maintain a safe distance as a way of coping.But in some cases avoid substances to gain acceptance by family members.
"I don't like to let them know what am doing and sometimes I normally go out in the evenings just to avoid being stigmatized that I smoke" "I don't do it where people are, I hide and do it.I feel that's a stigma to me" "I avoid going to places that I will be stigmatized most especially in a gathering of my mate, I don't go there because I don't want to be stigmatized…It helps me to reduce, to avoid stigma" However, Studies suggest that persons with SUDs are easily avoided by members of the public [22].

Reduced Interactions
Findings showed that participants engaged in fewer interactions with other people as a means of coping with stigma.According to respondents in this study, the lesser they associate with people, the less likely they are to experience stigma.This is evident by some of the responses below: "Because most people in my area their eyes are open, they normally see that I smoke so I try to reduce the outing I go" 100 "…then it goes to a time that anytime my siblings are going out I will not like to hang out with them because of that fear, I choose not to" Most participants feel there is no need to interact with people as a measure of preventing stigmatization.According to Lavack, stigma is a common experience of people with substance use disorders thus discouraging them from participating in social activities [23].Adlaf et al added that families of persons with SUDs presume that substance users should be in control of their behaviours instead of using substances [22].

Conclusion
The various ways that persons with substance use disorder experienced stigma from family members included: exclusion from decision-making, being ignored, and refusal of assistance.Consequent upon experience of stigma persons with substance use disorder cope with by: engaging in more substance abuse, been indifferent, avoiding other people, and reduce interactions.By en large, stigmatisation only worsen the use of substances and family members contribute to this menace.This maladaptive coping mechanism create a circle of stigma and substance use.

Limitations
The study only considered participants in a treatment facility, their responses may be in line with their experience of being in a drug treatment facility, and this may interfere with their responses.Recommendation This study suggests that family members should consider substance use as a public health problem and hence work toward helping the sick regain good health without discrimination to their health challenges.We also recommend that future studies should include SUDs and their family members.

Conflict of interest
All conflicts were well resolved among the authors.

Table 1 :
Above provide the frequency and percentages of 261 participants with substance use disorder, their sex, age range, marital status and type of family, these participants are drawn from a treatment facility in north central.