This study, the first of its kind to examine public stigma towards people who use substances in South Africa, had four important findings. First, high levels of public stigma were reported for all classes of substances investigated in this study. Specifically, the average scores on the AQ-9 for the various classes of substances ranged from 4.8-6.2 (well above the neutral score of 4.5); indicating that people who use substances are viewed negatively by the general population. Furthermore, as these AQ-9 scores are higher than those obtained for depression (4.7), schizophrenia (4.9), panic disorder and PTSD (4.9) by a previous study that used similar methods and was conducted in a similar location [10
], these findings suggest that the South African public view people who use substances in a more negative light than persons with other mental disorders. Although it is plausible that between-study factors could have partially accounted for this difference, this finding is in keeping with results from previous studies conducted in other contexts [12
]. One explanation for this difference may lie in attributions of personal culpability that are more often made about people with substance-related problems compared to people with other mental disorders, especially when these mental disorders are viewed as having structural causes [25
]. These findings suggest that in order to reduce the high levels of stigma towards people who use substances, public mental health literacy programmes need to be expanded to include better information about substance use disorders. For example, accurate information about the neurobiological roots of substance use and other mental disorders may help challenge attributions about personal responsibility for substance use disorders. Given our findings of low levels of mental health literacy relating to substance use disorders, this may be a powerful intervention for reducing stigma towards people who use substances [27
Second, all the characters in the vignettes were viewed equally negatively by the respondents regardless of the type of substance being used; with the exception of the cannabis user who was considered significantly less “dangerous” than someone who uses alcohol. These findings are inconsistent with previous studies conducted in developed country settings that found the use of “harder” drugs (such as methamphetamine or heroin) to be rated more negatively than the use of “softer” drugs such as alcohol and cannabis [28
]. One explanation for why respondents may have viewed people with alcohol problems as equally as dangerous as people who use “harder” drugs may lie in the high prevalence of problem drinking in South Africa [1
] and the large burden that alcohol places on communities in terms of alcohol-related injuries, alcohol-related violence and alcohol-related crime [30
The third important finding is that publicly held attitudes towards women who used substances differed from those held towards men. Although attributions of pity, dangerous, blame, anger and segregation did not differ between men and women, vignettes of women who used cannabis and methamphetamine evoked more negative attributions from respondents (namely avoidance and coercion in treatment) than vignettes of men who used these substances. This is not altogether surprising given previous research in South Africa and elsewhere which has noted that women with substance use disorders are perceived more negatively than men [5
]. This may be because women’s drug use is strongly associated with perceived inability to fulfil traditional gender roles, such as taking care of dependent children [31
] and also because methamphetamine use, in particular, is strongly associated with discourses of female sexual availability and “immoral” behaviour [5
] which goes against widely held beliefs about appropriate (conservative) female sexual conduct in a predominantly patriarchal country [32
]. In contrast, the vignettes of women who used alcohol evoked positive responses (of offers to help) compared to those for men, which evoked responses of coercion into treatment. This finding is inconsistent with earlier studies, conducted in developed country settings, which reported high levels of stigma towards women with alcohol-related problems [33
]. While the reasons for this unexpected finding are not clear, one potential explanation may lie in public perceptions that women’s drinking is less associated with adverse social consequences (such as crime and violence) than men’s drinking [34
]. Nonetheless, this explanation requires further investigation through qualitative research that unpacks the reasons why the public perceives men with alcohol-related problems in a more negative light compared to their female counterparts.
Finally, it appears that people who use substances more frequently held differing attitudes towards people with substance use disorders than those who reported using substances less often. Although attributions of pity, dangerous, blame, anger and segregation did not differ between users and non-users, respondents with higher substance use involvement scores were less likely to offer “help” and more likely to report wanting to “avoid” the characters in the vignettes than respondents with low substance use involvement scores. In a similar vein, respondents who had received previous substance abuse treatment were more likely to “blame” the individuals in the vignette for their substance use than those who had never received treatment. These findings may be explained by previous research examining self-image bias in drug use attributions which found that people who use substances were more likely than non-users to make stable, less controlled and more dispositional attributions about their own use and other’s use of substances [35
]. It is argued that substance users often rationalize their own behaviour by adopting an “addicted” explanation of substance use, minimizing personal responsibility for their behaviour [36
]. These findings may also reflect community norms which distinguish between people with unproblematic substance use and those who have developed substance use disorders; with the latter being viewed as “mad, “bad”, and having “lost control” [5
]. These norms may result in people who use substances wanting to distance themselves from individuals with substance use problems. These possible explanations however require further investigation.
These four findings should be considered in the light of some limitations. First, these data are based on self-report and are therefore subject to the limitations of self-report bias. Second, responses may have been influenced by social desirability, thus leading to an underestimation of stigma levels. Third, because of convenience sampling, the results may not be generalizable to the broader South African population, although we did try to ensure that the sample was broadly representative of the socio-demographic composition of the population in the Western Cape Province where the study occurred. Related to this, although fieldworkers randomly approached people to participate in the study, they may have inadvertently self-selected participants to approach, hence biasing the sample. Finally, the vignettes used to elicit attitudes may provide only a partial picture of the disorder. Reading a description of an individual’s symptoms may not directly relate to one’s ability to recognize symptoms of psychopathology. Similarly, a self-report describes one beliefs about what one would do when confronted with a particular situation, but it does not describe what one actually does in that situation.