Background information on participants
The demographic information of all FGD participants are summarized in Table
. The proportion of widowed and divorced women was very high considering the relatively young age of the participants.
Demographic information for allFGD participants
Physical health problems
The most pressing health problems identified by these women were explicitly and implicitly associated with their dependence on drug and alcohol use. Many of the women spontaneously mentioned the symptoms of withdrawal from drugs and alcohol as their major health concern, and consequently associated the use of drugs or alcohol with feeling better.
"P1: People who use drugs are okay. They experience sickness only when they don’t have their daily dose. Without it we can’t even move, when people talk nicely to us, we take it very negatively. We face no health problems when we are on drugs. When we are high on drugs, we become smarter."
"P2: We are sick only when we don’t do drugs. Without our daily dose, we experience body aches… and start fighting with our husbands and children… but when we are on drugs, we are relieved of all the body aches and when we are not on drugs, the sickness increases. (FGD1 Dimapur, Nagaland)"
"P: Rice beer users also experience shaking of hands if they don’t drink. We feel scared when not drinking. (FGD2 Dimapur)"
For these women their health problems were associated with the absence of drugs or alcohol, rather than the presence of them. This is a different construct from that of the KIs who mostly perceived the presence of drugs and alcohol as the source of poor health for users.
A number of reproductive health problems were reported including unwanted pregnancy leading to both abortion and birth of children, white vaginal discharge, irregular or absent menstruation, and STIs – syphilis and gonorrhoea were named in particular. When the women suspected they had an STI, they often tried to self-treat rather than suffer the embarrassment of seeking diagnosis and treatment from a health professional. Long periods of amenorrhea were identified by the women using heroin in particular, and irregular menstruation contributed to late detection of pregnancy. In some cases of pregnancy, the identity of the father was difficult to ascertain, or the father refused to acknowledge paternity, with the result that some women were single parents to their children.
A lot of the participants, both FGD participants and KIs, identified a range of gastro-intestinal complaints as problematic for female alcohol users in particular, especially gastritis, stomach problems, liver problems, hepatitis, lack of appetite, weight loss due to poor food intake, diarrhoea, constipation, and nausea and vomiting. Drug overdose was mentioned as a health risk by many participants and some of the FGD participants provided graphic descriptions of their friend’s and their own experiences of overdose. Much less commonly mentioned were HIV, TB, and HCV.
Mental health problems
Depression, stress and tension were frequently mentioned as a problem for women who use drugs and alcohol. Loss of hope was clearly expressed by some participants – many were resigned to their situation and could see no means of escape, and therefore, no viable future for themselves.
"P: No women who drink and do drugs are happy with their lives. (FGD2 Dimapur, Nagaland)"
"KI: If we look at their mental status, their motivation towards life and hope is very low. They are living for the sake of living. Once they die, then it is over, this is what they think. They don’t have any hope for the future. Being women, they also want to be a part of family where there are children, a husband and all. But it is only a dream to them. Sometimes we ask them “What is your wish for your life?” They answer “To live a life in a family like before” - this is their wish in life… They don’t have any hope for living a normal life. I think it might be the reason why they don’t want to go for health treatment or anything else. They think that even if they were free from drugs, they don’t have any place to go for a living. (KI3 NGO Project Manager, Manipur)"
Social and economic problems
The women drug and alcohol users in this study experienced a number of social and economic problems including social exclusion, violence, concerns about children, and financial difficulties resulting in lack of basic needs such as food, health care and medicines. These problems were often of much greater concern to them than their physical health problems.
Social judgment and consequent exclusion, including rejection by families were commonplace features of these women’s lives, and clearly a major source of distress for them. Family abandonment preceded drug and alcohol use for some of the women, and was therefore perceived to be a cause of it, while for other women, family abandonment was a direct consequence of their drug and alcohol use. Sometimes the women deliberately stayed away from their families because they felt ashamed of their situation. Exclusion from the church was also frequently mentioned, and feelings of self-stigmatization and guilt were evident.
"P: Due to our No. 4 [heroin] use we have guilty feelings and are scared of our family. Even if we go home our family doesn’t want us to be at home, due to our drug habit. (FGD4 Churanchandpur, Manipur)"
"P: Due to alcohol use we do not want to participate in church or social gatherings. We prefer to be with our friends – we often drink together and we are scared to enter the church building. There is the feeling that they are staring only at us, so we are keeping aloof from the society and church. (FGD5 Churachandpur)"
Several of the women in this study provided vivid descriptions of being subject to emotional and physical violence, including rape. The source of violence included families, husbands, army, police, pressure groups (women’s and youth groups as well as underground groups) clients, and chiltus (local gangsters). The violence sometimes took the form of social humiliation e.g. the women were tonsured and publically scolded for the perceived immorality of their lifestyle.
"P: I have faced many hardships as I need money for No. 4 [heroin]. Male customers invite us and say they will pay the money at the place, and when we go to the place they have lied to us, and they rape us and will not give even 25 paise, and then they will run away. (FGD4 Churanchandpur, Manipur)"
"KI: They are facing a lot of violence. They get caught by some strange men in the hot spots and are having sex forcibly - they don’t get any money but get beaten up by these men. Very recently one incident happened where they were caught by some men who inserted a stick inside their private parts. It is very hard to hear about such inhuman behaviour, but it is common among the women who are chronically dependent on drugs and doing sex work. Who will complain to police for their sake? No one complains. If it happened to an ordinary housewife people would come out in support. Community people don’t like them. (KI8 NGO Project Manager, Manipur)"
According to participants, the women who use drugs and alcohol could themselves be perpetrators of violence when under the influence of alcohol in particular, and sometimes children were the target of their violence. The situation for some children of women who are drug and alcohol dependant was described as precarious, especially if the father is also a substance user or is absent. Several participants related instances of child neglect and mistreatment when children remained with their mother. This neglect took the form of poor supervision, inadequate provision of food, and limited access to education.
"P: Sometimes, when I take my daily dose and am high on drugs, I can teach my children very well. But sometimes when I don’t take my dose and experience turkey [drug withdrawal] I get mad and put that frustration onto my child and instead of taking care, I hit the child. When my thoughts are not much on getting my drugs I can teach the child, but when my thoughts are all focused on where and how to get my dose, I forget about my child. (FGD3 Dimapur, Nagaland)"
Some children were being cared for away from their mothers by family members or in orphanages, and this was described as a major source of guilt and pain for their mothers. The women’s inevitable financial difficulties led to many other problems such as lack of shelter, lack of food, and inability to provide not only for themselves but also for their children.
Barriers to accessing health care
A number of barriers to accessing health services were identified by both the KIs and the women drug and alcohol users. The women’s own sense of shame, which was often deeply felt, or their reluctance to self-identify as a drug or alcohol user coupled with actual and anticipated discrimination from health care providers meant that they did not generally attend health care services. When the women experienced a health problem that could not be ignored, they mostly consulted with a pharmacist or a health worker from an NGO clinic. They generally avoided the government services because they feared being treated poorly, and the private services because they could not afford to pay.
Even attending the NGO services was sometimes problematic, as to do so could result in the woman being identified as HIV positive, a drug user or a sex worker (whether or not she was). The women understood that the NGO services were only available for women who were HIV positive, injecting drug users, or sex workers, and thus precluded non-injecting drug users and alcohol users.
"P: Injecting users are availing the services but oral users who are hidden do not want to avail the services because they do not want others to know they are taking drugs."
"F: What would be the reason that prevents them from accessing the services and programs they need?"
"P: They do not admit to themselves that they are an addict – they are hidden. Some do not want others to know about their drug use. Saying it is a way of self-disclosing our identity… In spite of telling our friends about the available services they do not listen to us. People have an idea that the services are only for positive people. (FGD3 Churachandpur, Manipur)"
"Another perceived short-coming of the NGO services was that the range of services offered was limited mainly to the provision of condoms, needles and syringes, whereas the women’s most pressing problems were unrelated to HIV prevention, and often beyond the scope of services offered by the HIV prevention NGOs. These problems included family conflict, social exclusion, mental health problems, drug and alcohol dependence, and financial difficulties."
"P1:They conduct group discussions with us. As part of the program, syringes and condoms are also available. No other programs except group discussions [they all laugh]."
"F: Can anyone tell about other services?"
"P2: Nothing, except syringes and condom distribution."
"F: Excluding syringes and condoms, any other program you access?"
"P1: No. With four to five participants they often conduct group discussions where they talk on the topic of prevention [laughs]. We are fed up of hearing and listening to the same topic which we have known, we already know [all of them laugh]."
"P2: We hesitate to attend the meeting assuming that the same message will be given."
"P3: We know about STIs and HIV. (FGD3 Churachandpur, Manipur)"
Other barriers included the cost of services and medicines, the inability of the women to travel away from their own locality, and poorly functioning or absent health services.
"KI: Some of the women say ‘We go to the hospitals but the doctor was not there, nurse was not there, and there was no medicine’. So if at the first shot, first time they go, if they don’t meet the doctor they don’t want to go the second time, they feel very discouraged, so lots of motivation is required. We tell them to go and they say ‘We’ll go, we’ll go’, but they don’t go. Yeah, access is one thing, plus facility availability in the hospital is also another thing. If everything is always available I’m sure they will be motivated to go, but many times they don’t get what they need and they are asked to buy [medicines], and they don’t have money to buy. (KI2 NGO Director, Nagaland)"
Health and other service needs
Women-only health services
An integrated health service for women, staffed by women, was seen by the majority of participants as an important strategy for increasing access to care for female drug and alcohol users.
"KI: And there should be more women specific health centres – I don’t know whether it would be possible or not, but if there could be more health centres specifically for women irrespective of whether they are drug or alcohol users, for women in general. Any women can just walk into the centre and can get services. If something like that can be tried out I am sure it will go a long way in improving the health status of our women in general and maybe even the drug users in particular. (KI2 NGO Director, Nagaland)"
Related to the concept of women-only health services was that of women-only drop-in-centres (DICs) at the NGOs, as the current DICs are very male-dominated, and this actively deters the participation of women.
"KI: The women often say they feel uneasy to pass through the DIC and go for treatment as the males often tease them, and even if they did not tease them, they still feel uncomfortable because it is male dominated. (KI13 Outreach Worker, Manipur)"
The participants envisioned a women-only DIC as a place to rest, have tea and snacks, with make-up and other toiletries as well as bathing and clothes washing facilities. Another suggestion was the appointment of more female outreach workers and peer educators as part of the targeted HIV prevention programs. Legal advice services, children’s services, nutrition programs, and community mobilization programs were also mentioned as desirable services by the KIs in particular.
Detoxification and rehabilitation services for women
The women frequently emphasized the desperate need for women-only and women-friendly drug and alcohol detoxification and rehabilitation centres that are low cost and can accommodate children. They were also adamant that some sort of short-stay home/half-way house accommodation was necessary following completion of the rehabilitation program to reduce the very real risk of relapse, especially as women are not so easily reconciled with their family compared to men, even when recovered. The transition from rehabilitation to social reintegration was seen as a very vulnerable time for these women. Another important component of rehabilitation mentioned by many participants was meaningful vocational training, and access to micro-finance opportunities to start up small businesses.
"P: A short stay home [is needed] if the course in the rehab centre is short. After the detox period, vocational training would be very helpful for us. After completing the rehab course there should be something that can fully occupy our minds, this way it will be easier to forget what we desire. If not, after the course of rehab, if we stay the same way, it is very easy to use it again. A rehab centre is what we need in Churachandpur. (FGD3 Churachandpur, Manipur)"
It may not be necessary to admit all women seeking detoxification to a residential program, as community based programs were an alternative model of care mentioned by some KIs.
Mental health care
The need for mental health care and counselling for women drug and alcohol users was particularly emphasized by many participants, both the women themselves and the KIs.
"P: A good doctor, a psychiatric doctor – most of us are using alcohol and drugs due to depression and negative thinking – to provide quality counselling. If counselling and medical treatment are provided I believe this may be more helpful than syringes and condom distribution. Due to depression we are half-hearted. A doctor to be available in the NGOs to help us psychologically. (FGD5 Churachandpur, Manipur)"
Sensitization of health care workers and the general community
The need to raise awareness of the health and other problems faced by women drug and alcohol users among health care workers and the general community was frequently mentioned. The women anticipated and sometimes received poor treatment when seeking health care, and this was a major barrier to access.
"KI: Particularly in the health set up, whether in the government sector or the private sector, or the NGO sector, I think the sensitivity towards women, the issues of women – gender sensitivity – I think that is one area we are very much lagging behind. A woman should be made comfortable even if she is into drugs or alcohol. I think there has to be a lot of education and sensitization on gender sensitivity – that is one area that can be improved upon. (KI2 NGO Director, Nagaland)"
Free access to medicines and general health check-ups
Several FGD participants were of the view that general health services, integrated with STI testing and treatment services, should be made available to the women for free. Some were quite strident about their need for free medicines to treat the symptoms they were experiencing, especially treatments for gastritis and liver problems, a range of vitamins and minerals, and ‘glucose drips’. Frequently the drugs and vitamins were identified individually by name, and at times even by trade names e.g. ‘Liv 52’. They complained that they were repeatedly given the same medicines when attending the NGO clinics and wanted a range of medicines to be available for them free of cost. Some identified the restricted access to medicines as a factor that deterred women from returning to the clinics.
"P1: What I want is, as most of us have a gastritis problem, we need medicine for liver, stomach. And there are some who are dying when they skip food for two to three days – for such persons, they need vitamin and glucose."
"P2: Mostly drug and alcohol users have gastritis problems. I am not criticizing the existing services, but when we access free medical check-ups, free medicine is not available for us. So a place where free medicine for liver, stomach, and glucose should be available. When I start drinking alcohol I can stay without food even for three months, and if I stop drinking I am dying, and after four to five glucose drips, I will be alright again. (FGD5 Churachandpur, Manipur)"
Assistance to meet basic needs
The need to help women drug and alcohol users find employment or livelihood opportunities was also mentioned. As many of the women had been rejected by their families, they often lacked a safe and secure place to sleep.
"P: We need a place to sleep as we drug user are busy hunting for money for our drug use, and most of the time we are not allowed to enter our own house. We need a proper place with food as we cannot sleep in the street, and this will also help us mentally with our trouble in finding a place to sleep. (FGD3 Churachandpur, Manipur)"
A place for engaging in sex work
Some of the FGD participants who were sex workers identified the need for a safe place where they can both live and sell sex.
"P: We need a house where we can also sleep and for sex work. Where one of the staff will play the role of manager, and with a clinic attached."
"P: A place to sell sex and earn money for IDU sex workers."
"P: The pimps are taking advantages of us, they disregard us and often cheat us, and they never pay the exact amount of our share."
"P: What you said is true. We have to share the money with the pimp fifty-fifty. So if we could have a place where we can sell sex and earn money. We can share fifty to the pimp manager. Fifty from the manager’s share should include house rent and food."
"P: If three or four or up to seven of us can stay in a place in such a way we could earn and live properly."
"P: This way we can stand as a strong self help group."
"(FGD 3 Churachandpur, Manipur)"