Research Report by Kikonyogo Robert

CAUSES OF ALCOHOLISM AMONG THE YOUTH A CASE STUDY OF MUKONO TOWN COUNCIL MUKONO DISTRICT BY KIKONYOGO ROBERT 08/U/10100/BGE/PE REPORT SUBMITTED TO THE DEPARTMENT OF PSYCHOLOGY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE BACHELOR OF GUIDANCE AND COUNSELLING OF KYAMBOGO UNIVERSITY AUGUST, 2011   DECLARATION I Kikonyogo Robert declare that this work is original and has not been submitted to any other university before. Signature: ……………………………………………………… KIKONYOGO ROBERT Date: ………………………………………….…… This proposal has been submitted for examination with the approval of the supervisor, Mr. Ssemakula Paul . Signature : ………………………………………………………….. MR. SSEMAKULA PAUL Date: …………………………………………………………. . ACKNOWLEDGEMENTS I would like to thank MTC-Mukono District for supporting me in my field research and for granting me permission to use their project as a case study. I would also like to thank my mother Mrs.Nakayiza Cissy for her encouragement during the studies and for having confidence in me and for encouraging me to be who I am. Thank you to MTC staff for identifying and introducing me to the field respondents. Special thanks to Mrs. Sharon and Mr.Ssenfuka Samuel for assisting me during data collection. Special thanks to my supervisor Mr. Ssemakula Paul, my lecturers and course mates for the support extended to me in many ways. Most importantly, my participants, without whom this study would not have been possible. Their lived experiences which they openly shared with me made me realize that “the beauty of life does not only depend on how happy you are, but on how happy others can be because of you”. Their experiences encouraged me to make sure that their plight and needs are highlighted and adequately addressed. Finally, and most importantly, I wish to thank the almighty God for the strength, courage and motivation He gave me throughout my studies. I am sure that without His blessings I would not have done it. ABSTRACT The study covered the alcohol programs of the Mukono District in Uganda, taking the case study of Mukono Town Council. The specific objectives of the study were: to assess the activities carried out by Mukono District in the alcohol program, assess the reactions of the various stakeholders towards the program, examine the constraints by the district and the stakeholders and explore opportunities for the treatment and prevention of alcohol abuse. The study was qualitative and descriptive. Key informant interviews were used to collect data from 50 respondents representing a wide range of stakeholders. Findings indicate a number of reactions towards the program. Some respondents felt that the problem of alcohol should be taken seriously and that alcoholism should be targeted as a disease. The respondents were supportive before the program and wanted it to continue. Community education was seen as having a positive effect as reflected through community initiatives. Some respondents were not in favor of controlling alcohol and recommended that all initiatives to control alcohol be community-driven. The program faced a number of challenges including: perception of alcoholism, stigma of alcoholism, little resources, lack of government policy on alcohol, the nature of the disease, shortage of drugs, poverty in the community, low capacity of medical staff, culture of alcohol and lack of family support to alcoholic patients. Despite the limitations, the program presented opportunities for alcohol programming such as the disease concept of alcoholism, successful treatment, special training for medical staff, community education, a combination of alcohol programming with other community development initiatives and ways of eliciting political will. The study yielded the following recommendations: need for an alcohol policy, alternative income generation activities at a household level, special addiction education in medical schools, and surveillance of alcoholism trends by the health ministry and a common working definition of alcoholism. Alcoholism should be regarded as a public health problem. TABLE OF CONTENTS DECLARATION II ACKNOWLEDGEMENTS III ABSTRACT IV TABLE OF CONTENTS V LIST OF TABLES IX LIST OF ABBREVIATIONS X CHAPTER ONE: GENERAL INTRODUCTION 1 1.0 Introduction 1 1.1 Background to the Study 1 1.2 Problem Statement 4 1.3 Objectives of the Study 5 1.3.1 General Objective 5 1.4 Scope of the Study 5 1.5 Significance of the Study 6 1.6 Organisation of the Study 6 1.7 Definition of Key Concepts 7 1.7.1 Alcoholism 7 1.7.2 Alcohol Abuse 8 1.7.4 Detoxification 8 1.7.5 Chemical Dependency 9 CHAPTER TWO: LITERATURE REVIEW 10 2.0 Introduction 10 2.1 Treatment and Prevention of Alcoholism 10 2.1.1 The concept of Alcoholism and Challenges in Comprehension of the Disease of Alcoholism 10 2.1.2 Best Practices in the Treatment of Alcoholism: Challenges and Opportunities 11 2.1.3 Effectiveness of Interventions 20 2.1.4 Treatment Environment: Challenges and Opportunities 12 2.1.5 Family Involvement in Treatment of Alcoholism 12 2.1.6 Drug Treatment for Alcoholism: Challenges and Opportunities 12 2.1.7 Skills Training, Social Reintegration and Collaboration with the Judiciary in theTreatment of Alcoholics 13 2.1.8 Nutritional Rehabilitation: Challenges and Opportunities 14 2.1.9 Support Group Formation: Challenges and Opportunities 15 2.1.10 Prevention of Alcoholism and Alcohol Abuse 15 2.1.11 The role of Education in the Treatment and Prevention of Alcoholism 17 2.1.14 Change of Norms and Behaviours 18 2.1.19 Conclusion 21 CHAPTER THREE: METHODOLOGY 22 3.0 Introduction 22 3.1 Research Design 22 3.2 Study Area 22 3.3 Study Population 23 3.4 Sample Size 23 3.5 Sampling Procedure 25 3.6 Methods of Data Collection 26 3.7 Procedure for Data collection 27 3.8 Data Management and Analysis 27 3.9 Methodological and Practical Limitations of the Study 27 CHAPTER FOUR: STUDY FINDINGS 30 4.0 Introduction 30 4.1 Activities Carried out by MTC in the Prevention and Treatment of Alcoholism 30 4.1.1 Community Education and Capacity Building 30 i) Community Education 31 ii) Production of Alcohol Related Information, Education and Communication Materials 36 iii) Capacity Building of Stakeholders 37 4.1.2 Care and Support 39 4.1.2.1 Psychosocial Support 40 i) Motivational counseling 40 ii) Referral 41 4.1.2.2 Medical Treatment 44 4.2 Reaction of the Community on Treatment and Prevention of Alcoholism 46 4.2.1 Reaction to the View that Alcoholism is a Disease 46 4.2.2 Community Support for the Program 49 4.2.3 Participation in the Alcohol Education Program 51 4.2.4 Responses on Controlling Alcohol Production and Consumption 54 4.3 Challenges in Carrying out the Alcohol Program 61 4.3.1 Perception about Alcoholism 61 4.3.2 Inadequate Capacity to Diagnose and Effectively Treat Alcoholism 64 4.3.3 Negative Attitude by Health Workers 66 4.3.4 Stigma of Alcoholism 67 4.3.5 Lack of Social Support for Recovering Alcoholics 70 4.3.6 Program Design 71 4.3.7 Access to Detoxification Services 73 4.3.8 Lack of Essential Drugs for the Treatment of Alcoholism 74 4.3.9 Late Diagnosis 74 4.3.10 Insufficient Funds 75 4.3.11 Political Interference and Alcoholism 76 4.3.12 Community Attitude towards Drinking 77 4.3.13 Gender 78 4.4 Opportunities for Treatment and Prevention of Alcoholism 81 4.4.1 Presence of Treated Individuals in the Community 81 4.4.2 Availability of Specially Trained Health Workers 82 4.4.3 The Presence of Interested Stakeholders in the Community. 82 4.4.4 Community Demand for Action 84 CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS 85 5.0 Conclusions 85 5.1 Recommendations 87 5.1.1 Recommendations to MTC 87 5.1.2 Recommendations to Community 87 5.1.3 Recommendations to Local Government 88 5.1.4 Recommendations to Central Government 88 5.2 Areas for Further Investigation 88 5.2.1 The Family 88 5.2.2 The Public 89 5.2.3 The Society 89 5.2.4 The relationship between HIV, STDs and Alcohol 89 REFERENCES 90 Books 90 Websites 93 APPENDICES 95 Appendix 1: Interview Guide 95 LIST OF TABLES Sampling Table………………………………………………………………………………….31 LIST OF ABBREVIATIONS AA Alcoholics Anonymous MKN Mukono AIDS Acquired Immune Deficiency Syndrome MTC Mukono Town Council CDO Community Development Officer LC Local Council TPO Transcultural Psychosocial Organisation UNODC United Nations Office on Drugs and Crime UPPAP Uganda Participatory Poverty Assessment Process USA United States of America WHO World Health Organisation AMA American Medical Association NGO Non Governmental Organisation AA Alcoholics Anonymous VCPA Volunteer Community psychosocial Assistants CBOs Community Based Organisations

EU European Union NUSAF Northern Uganda Social Action Fund WHO World Health Organisation SOS Save Our Souls SWOC Strengths, Weaknesses, Opportunities and Constraints CHAPTER ONE: GENERAL INTRODUCTION 1.0 Introduction The study was carried out from Mukono Town Council (MTC), Mukono District. The research focused mainly on the youth by identifying the causes of alcoholism in the District. The term "alcoholism" refers to a disease known as alcohol dependence syndrome, the most severe stage of a group of drinking problems which begins with binge drinking and alcohol abuse. The study mainly focused on the causes of alcoholism in Mukono Town Council Mukono, District. The major aim of the study was to identify and analyze the causes and prevention of alcoholism among the youth. Officially, binge drinking means having five or more drinks in one session for men and four or more for women. Another definition for binge drinking is simply drinking to get drunk. It is the most common drinking problem for young people, under age 21 1.1 Background to the Study Mukono Town is a municipality in Mukono District, Central Uganda. The town is administered by Mukono Town Council, an Urban Local Government within Mukono District Administration. Mukono Town has links to the English town Guildford. Mukono Town is bordered by Kalagi to the north, Kira Town to the west, Lake Victoria to the south and Lugazi to the east. It lies 27 kilometres (17 mi) east of the central business district of Kampala, Uganda's capital and largest city. The town occupies approximately 31.4 square kilometres (12.1 sq mi) of land area. The coordinates of the town of Mukono are: 00 21 36N, 32 45 00E (Latitude: 0.3600; Longitude: 32.7500). Mukono is one of Uganda's fastest growing urban areas. The 2002 national census estimated the population of the town at 46,506. In 2010, the Uganda Bureau of statistics estimated the population at about 57,400. Administrative Units Mukono Town is divided into four (4) administrative units called Wards. These are: Ggulu, Nsuube, Namumira and Ntaawo. Alcoholic beverages are produced by the fermentation of yeast, sugars and starches. Ethyl alcohol or ethanol is the intoxicating ingredient in alcohol beverages. Alcohol is a depressant; it slows down the function of the central nervous system. It can impair judgment and alter a person’s emotions, perceptions, movements and reactions, vision and hearing. When consumed in small amounts, it can help a person feel relaxed and less anxious. When consumed in larger quantities, alcohol can have detrimental effects on one’s health as well as social relations and financial well-being. In Mukono alcohol is made in the following ways: Tonto or mwenge bigere is a traditional brew produced by fermenting banana juice by adding sorghum. It is mostly consumed in central and western Uganda, where growing banana is a major agricultural activity, and in urban areas all around the country. In many parts of the country, brewing tonto is an important source of income. It is consumed from small gourds using straws at social gatherings and bars. The alcohol content in tonto ranges from 6-11% This means that the total volume of pure alcohol (ethanol) in any volume of tonto ranges from 6-11%. Ajon or malwa is an alcoholic beverage made from finger millet. It is widely consumed in eastern and northern Uganda and in urban areas around the country. The alcohol content of ajon ranges from 6-8% v/v. Ajon is considered to be highly nutritious and a source of vitamins, calcium and iron (1). Omuramba is made from sorghum. It is mostly consumed by people from Kigezi, in southwestern Uganda. It is normally taken in wooden cups at marriage ceremonies, parties and other social gatherings. Kweete is made from equal parts maize and germinated millet in many parts of Uganda Most of the above traditional drinks can be distilled to produce a more concentrated and relatively pure beverage called waragi. Waragi can be as high as 40% v/v pure ethanol, if not higher. Molasses can also be used to produce waragi, as is done in sugar-cane growing areas in Mukono Uganda. Kasese is another popular illegal extra-strength waragi. Waragi is available both in legally bottled form and in the illegally, home-made form often referred to as enguli. Enguli is the main form of alcohol consumed in Uganda followed by fermented home-made drinks The World Health Organization estimates that there are about 2 billion people worldwide that consume alcohol. Of the 2 billion, approximately 76.3 million have a diagnosable alcohol use disorder, such as excessive drinking and alcohol dependence. Worldwide, adults (age 15 years and older) consume on average 5 liters of pure alcohol from beer, wine and spirits each year. For the Africa region, the adult (15 years and older) consumption of alcohol is about 4 liters of pure alcohol each year. The WHO Global Status Report on Alcohol released in 2004 showed that in Uganda, 19.47 liters of pure alcohol are consumed per capita each year. This is nearly 4 times higher than the worldwide average and 5 times higher than the Africa region average, making Uganda ranked number 1 from 189 WHO member states in level of alcohol consumption. 19.47 liters of pure alcohol is about 1.62 liters of pure alcohol consumed each month. If one standard drink equals 15.2 mL of pure alcohol (12g of pure alcohol equals15.2 mL in volume, which is defined as a standard drink in the study from which this WHO data comes from), this would average to approximately 107 drinks/month consumed per capita in Uganda. Statistics on how many people get alcohol related physical, mental and social complications in Uganda are not available, but competent authorities, community leaders and development agencies believe the number is big and the problem needs to be addressed. Research has established a relationship between HIV/AIDS and alcohol (Kigozi and Kasirye 1997), and the Uganda AIDS Commission has pointed out that efforts aimed at reducing the abuse of alcohol should be undertaken (National Strategic Plan 1998-2002 of the Uganda AIDS Commission). However, the Health Sector Strategic Plan does not have any specific plan to deal with the problem. Child abuse, domestic violence, especially against women, youth and unwanted pregnancies, automobile accidents, crime and sexual abuse cases have been largely attributed to Alcohol abuse and abuse of other substances in certain parts of Uganda. Despite this overwhelming evidence, Uganda does not have an alcohol policy to assist the public to guard against or mitigate the bio-psychosocial complications of alcoholism and alcohol abuse. 1.2 Problem Statement The youth in MTC are at risk as far as alcohol use and abuse is concern. The age of starting to drink alcohol is getting lower every year. Both youth in school and particularly those out of school (homeless, street children, children who live in slums, etc…) consume too much alcohol and abuse other drugs. Recommended approaches to promoting responsible drinking behavior among the youth are peer-to-peer education. Peer-to-peer prevention approach should occasionally be reinforced by public film and drama shows. One recommended approach for the youth is to begin with discussions to understand their opinions, their beliefs and what they consider to be benefits vs. negative consequences of alcohol abuse. They should be questioned as to why they drink and made to understand that every drinker is a potential alcoholic. Many youth believe that people who develop alcohol related problems are those who can’t control what they drink. They need to be convinced that all alcoholics at one point believed as they do now and eventually became alcoholics without understanding how they came down that path. Messages to the youth should first of all stress that anyone under 18 should not consume any alcohol. Those >18 year of age who chose to drink should do so in a manner that is not harmful. Causes and prevention of alcoholism that is under this study is a new approach in Uganda, and treating a problem, which many people do not consider a problem is a challenge in itself. Attempts in Uganda tend to follow or modify the European/USA models of treatment. Cultural and other social aspects in Mukono may pose specific challenges and there is need to understand these challenges as well as opportunities if treatment and prevention programs are to succeed. 1.3 Objectives of the Study The study was conducted based on the following general objective: 1.3.1 General Objective This study is to help counselors and researchers to examine, find appropriate programs and policies to prevent the causes of alcoholism among the youth in Mukono District. 1.3.2 Research questions 1. What are the causes of alcoholism among the youth? 2. What intervention measures are in place to curb alcoholism? 3. How can alcoholism be levered among the youth? 1.4 Scope of the Study The study covered the work of MTC in the communities in Mukono district Anthony Village. It covered the detoxification Unit in Mukono Health Centre hospital IV and prevention programs in the community. The study only sought to establish the causes of alcoholism and alcohol abuse among the youth. The study focused on community sensitization and education aspects, the detoxification unit, interviews with women brewers, people known to abuse alcohol.The category of the respondents include; Political leaders, Civic leaders, Religious leaders, Family leaders, Health workers, Community workers, Community members and children regardless of their educational, marital status, religious background. . 1.5 Significance of the Study It is hoped that the study will highlight the plight of the alcoholics and their families and contribute to the body of knowledge about public health (bio-psychosocial) problems in Uganda. The study will be used as one step to press a case for an alcohol and drug policy in Mukono District. Because alcohol permeates important cultural activities, alcohol is widely consumed by all people, male and female alike, young and old. Only certain groups such as Muslims and born again Christians are not allowed to drink and tend not to drink. Women and children are culturally not allowed to drink in public with few exceptions. The study will benefit youth both women and men among other people in the community to be aware of the negative effects by avoiding the causes of alcoholism in Mukono Town Council, Mukono Distrct. The findings of the study, it is hoped will help in preventing the causes and treatment programs for MTC and other organizations involved in public health and social development. The findings of the study shall be used as an advocacy tool for the need to support treatment and prevention of alcoholism and alcohol abuse. The study also identifies opportunities for the prevention of alcoholism and alcohol abuse in communities in Mukono District, Uganda. Despite the strict gender norms that govern what is acceptable for women to do in regards to alcohol consumption, it is women who brew and sell alcohol. Brewing and selling alcohol is an accepted economic activity in the general population. Poverty and lack of alternative income-generating activities for women has been cited as the main reasons for alcohol production. Incomes from selling locally brewed alcohol are often used for school fees. 1.6 Organization of the Study The study is organized in five chapters. The first introductory chapter presents the background of the study which forms the basis for the problem statement, objectives, significance of the study and the definition of the key concepts. The Second chapter gives an overview of the literature review that is related to the objectives of the study. Chapter three gives the research methods used in data collection and these include the geographical area of the study, research design, data collection methods, data analysis and the problems encountered during research and how they were solved. Chapter four presents the research findings, their interpretation and discussion. Chapter five presents recommendations and conclusions. Definition of Key Concepts 1.6.1 Alcoholism Alcoholism is a condition in which a person develops a bio-psychosocial dependence on alcohol and other related mood-altering substances, such as minor and major tranquilizers and sedatives. The person uses alcohol for short-term gratification. Obsession, compulsion and loss of control accompany the condition (Ketcham and Millam, 1988, Willcox, 1992, Ketcham and Asbury, 2000). When not using alcohol, the person suffering from alcoholism thinks, plans, and looks forward to drinking (WHO, 2003). This obsession interferes with living, but there is an overwhelming urge or compulsion to consume alcohol despite the long-term painful consequences. The alcoholic uses alcohol to relieve the pain caused by alcohol (Gorski and Miller, 1986). The World Health Organization estimates that nearly 62 million people worldwide suffer from alcohol dependence. Alcoholism, which is also known as alcohol dependence syndrome is a disease that is characterized by the following elements: (Healthier You, 2004) Craving: This refers to a strong need or compulsion to drink. Loss of Control: The frequent inability to stop drinking once a person has begun. Physical dependence: The onset of withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety when alcohol is stopped after a period of heavy drinking. Tolerance: The need for increasing amounts of alcohol in order to get a high. Alcoholism is a treatable but not curable (Healthier You,2004) 1.6.2 Alcohol Abuse This is said to occur when an individual uses alcohol excessively. The person may suffer from physical, social and psychological consequences as a result, but is not addicted to alcohol (National Institute on Alcohol abuse and alcoholism, 2003). Alcohol abuse differs from alcoholism in that it does not include a strong an extremely strong craving for alcohol, loss of control, or physical dependence. Alcohol abuse is also less likely than alcoholism to include tolerance (need for increasing amounts over time to achieve the same high (Healthier You, 2004) 1.7.3 Drugs Any mood altering chemical agent that produces changes in brain function by altering the chemistry of the brain. Such a chemical agent is called psychoactive (United Nations Drug Control Program 2003). Drugs discussed in this work are limited to aspects of alteration of emotions, thoughts and behaviour. Throughout this work, alcohol will be referred to as a chemical, a drug or a substance. 1.7.4 Detoxification Is the medical procedure of withdrawing somebody from physical chemical dependence. Detoxification is the first medical procedure used to help chemically dependent persons. The procedure helps the body system that has been operating in the presence of specific doses of alcohol to adjust to the absence of alcohol. If the procedure is not carried out, death could occur due to withdrawal symptoms. 1.7.5 Chemical Dependency The term chemical dependency is used interchangeably with the term addiction. It refers to a condition whereby by a person develops a biological, psychological and social dependence on a substance of abuse. She/he is unable to “function” without using the substance hereby referred to as a chemical. CHAPTER TWO: LITERATURE REVIEW 2.0 Introduction This part presents a body of related literature on the causes and prevention of alcoholism. This contains what different scholars, practitioners and recovering addicts say on the subject and disease of alcoholism, its causes and prevention. There is scanty literature on the causes, treatment and prevention programs on alcoholism and alcohol abuse in Uganda. The literature reviewed here is, therefore, largely from elsewhere in the world. The literature mainly centers on the best practice, challenges and opportunities in substance abuse programming and as well as lessons learnt. 2.1 Treatment Programs for alcoholism The methods of Causes and prevention are largely determined by the understanding and conception of the problem of alcoholism in a given context. (UNODC and WHO, 2004) 2.1.1 The concept of Alcoholism and Challenges in Comprehension of the Disease of Alcoholism among the youth Alcoholism is a commonly used term to describe a disorder marked by the chronic, excessive use of alcohol, resulting in psychological, interpersonal, and medical problems (Milam and Ketcham, 1983). The disease concept of alcoholism began in the late 1930’s. It took over from the stigmatising moral model, which blamed the deviant drinker and viewed him/her as a perpetrator of his/her own misfortune (Vannicelli, 2002). This attitude seems to be dominant in Uganda as evidenced in the Articles in the New Vision newspaper of October 23rd and November 3rd, 2003 where 238 police officers were dismissed from the force with no option for treatment. The work of Jellinek (1960) provided a breakthrough in the puzzling nature of alcoholism. In the disease model, alcoholism is viewed as (1) a genetically transmitted disease (2) with an irreversible progression, (3) eventuating in loss of control (Miller and Gorski, 1986, Vanicelli, 2002). In many communities this view of alcoholism may not be present and this may pose a challenge in programming and mobilizing the community and the families to support alcoholic individuals. 2.1.2 Best Practices in the prevention of the causes of Alcoholism The best treatment methods of alcohol dependence vary, depending upon an individual’s medical and personal needs. Some heavy drinkers, who are made to recognize or realize on their own, may stop drinking and recover (Ketcham and Asbury, 2000). Others recover by participating in the program of Alcoholics Anonymous or other self-help groups. Some alcoholics require long-term therapy, which in most cases includes hospitalization. Other people do not seek treatment at all due to a combination of factors, including ignorance of the symptoms of alcohol use disorders, the social stigma that still surrounds these disorders-that is the fear of being labeled an alcoholic-and an unwillingness to accept lifetime abstinence from alcohol as a treatment goal. In Uganda, some individuals may stop abusing alcohol on their, others within the capital of Kampala seek support from Alcoholic Anonymous groups as well as support groups within the church (personal knowledge of these groups). These groups meet in church premises in the city centre: Christ the King church, every Tuesday and Friday, and Kampala Pentecostal church. (Youth Aid, 2002). In a community that has a treatment and prevention program, it would be important to establish the effectiveness of the different approaches to treatment employed by the agency (MKN). 2.1.3 Treatment Environment Depending on the condition of the individual, treatment of alcoholism begins with detoxification, which safely rids the patient’s body of alcohol while treating any physical complications that develop from severe withdrawal symptoms, such as delirium tremens. Detoxification normally requires less than a week, during which time the patients usually stay in a specialised residential treatment facility or a separate unit within a general or psychiatric hospital. These facilities also offer extended services to alcoholics on their recovery. MKN, in collaboration with the District Directorate of Health Services, has a detoxification unit. It would be interesting to establish the effectiveness of this unit in changing the alcoholic patients’ drinking behaviors and the perception of the community towards the facility. 2.1.4 Family Involvement in Treatment of Alcoholism It is usual practice to involve individual counseling and group therapy to help a person who is alcohol-dependent adapt a new way of life, one that is not controlled by alcohol (Milam and Ketcham, 1988). The challenges and opportunities for employing this approach for alcoholic patients in Uganda have not been studied and/or documented. 2.1.5 Drug Treatment for Alcoholism Physicians may prescribe medications to help prevent alcoholics from returning to drinking once they have stopped (Ketcham and Asbury, 2000). The drug Disulfiram (sold under the trade name Antabuse) interferes with the way the body processes alcohol. Taken in a pill form daily, this medication generally has no pronounced side effects until the person drinks alcohol. Alcohol and the drug interact to produce a severe unpleasant reaction, including nausea, dizziness, headache, heart palpitations, and other problems. Alcoholics then associate the unpleasant reactions with alcohol and are likely to fear drinking. Naltrexone (ReViva) is a narcotic approved for use in alcohol treatment in 1995 (Ketcham and Asbury, 2000). Although scientists are not very sure of how it works, it is known to block craving for alcohol by shutting out the positive effects the person derives from drinking. Naltrexone and Antabuse work effectively when combined with counseling programs (Ketcham and Asbury, 2000). Treatment programs focus on helping the alcoholic understand the situations, feelings, and interpersonal interactions that trigger drinking. In Uganda, these drugs are not available. It would be important to establish the perceptions of the various groups involved in the treatment of alcoholics, whether they would recommend their use in a program like that run by MKN. It would also be important to find out from alcoholic patients whether they would welcome the use of such drugs if they were available. 2.1.6 Skills Training, Social Reintegration and Collaboration with the Judiciary in the Treatment of Alcoholics In addition to formal treatment programs, there should be other community resources, including vocational training, family guidance, religious counseling. Some countries such as South Africa, Poland and Finland have compulsory treatment programs for alcoholics who have committed crimes (Encarta Encyclopedia, 2003). It would be important to find out whether this approach is available in the MKN program and, if not, what are the reasons behind this. It would also be important to establish whether MKN gets referrals of patients who have committed alcohol related offences from the judiciary, the police and the local government structures. Existing laws and regulations should be consistently enforced. Broad community involvement and support has shown a reduction in underage drinking. When adults, parents, policy makers, and law enforcement officers signal their intent, it reduces alcohol abuse, especially among minors and those who provide them with alcohol. Public acceptance and political feasibility are of critical importance in selecting alcohol policies. The evidence for scope, seriousness and costs of alcohol problems has to be stated and the public helped to appreciate the case for policy choice (WHO, 1995). It is worthwhile finding out opinions about the role of policy and community participation in the regulation of alcohol in Uganda. 2.1.7 Nutritional Rehabilitation Nutritional Therapy is also part of the treatment procedure. Recovery from alcoholism requires good nutrition to counter the damage done to the body and to restore the neurotransmitter balance (Brain messenger chemicals). When alcoholics are not given sufficient diet, they are likely to suffer from depression and are more likely to relapse (Ketcham and Asbury, 2000). The majority of the population in the study area derives their income from subsistence agriculture, brewing local beer, petty trade, fish mongering, cutting and selling of timber, poles, grass and making ropes and granaries. In the months from May to July, there is food shortage (UPPAR, 2000). It would be important to find out whether the issue of nutritional therapy arises in TPO’s treatment program. 2.1.8 Support Group Formation In Alcoholics Anonymous (AA) meetings the individual learns that he or she suffers from a disease. Any feelings of unworthiness the individual feelings are countered by supportive group interaction. AA offers a twelve-step program to recovery. The twelve steps confront the problems of denial and urge the recovering alcoholic to help other alcoholics seek recovery. The fellowship also encourages the members to atone for the harm caused by the alcoholism and commit themselves to ethical lifestyles. In addition to AA, there should also be groups of spouses and children of Alcoholics. Alcoholism affects the whole family psychologically, socially, economically and physically (Bradshaw, 1993). It would be important to establish whether these groups exist, whether their formation poses a challenge and whether they are relevant to the community situation given the variations in the cultural and socio-economic contexts in which these groups operate worldwide. Due to the spiritual bent that many find in AA, other programs have been designed as alternatives to AA. (Ketcham, and Asbury, 2000) Examples of these include Rational Recovery (RR) and Save Our Selves (SOS) These use peer support to promote abstinence. 2.1.9 Prevention Programs for Alcoholism and Alcohol Abuse There is no available literature on the prevention programs in Uganda. The Health Strategic Plan 2000/01-2004/05 does mention that its programs and strategies are directly linked to the Uganda Participatory Poverty Assessment Report (2000). In this report, communities put alcoholism and alcohol abuse as a major cause of poverty. Poverty is directly linked to diseases. However, the Health plan does not name explicit ways of dealing with alcoholism. One has to guess at what needs to be done to mitigate and prevent the eminent escalation of this problem. According to the literature available on Uganda in the prevention of Alcoholism, the Uganda government in 1965 introduced an Act of Parliament regulating the production, sale and consumption of alcohol specifically, the locally distilled potent Gin (Enguli). The Act came to be known as the Enguli Act. The reason behind its formulation could have been the social, psychological and physical complications caused by the consumption of Enguli. Some writers also contend that it could have been driven by the effort to collect revenue from alcohol sales, a process which was begun by the colonial masters who created alcohol production and distribution monopolies (Willis, 2007). Part 1 of the Act says in part: (1) No person shall- (a) Manufacture, sell or otherwise deal in enguli; (b) Have in his possession any enguli; or (c) Have in his possession or under his management or control any apparatus used or intended to be used for the manufacture of Enguli, except under or by virtue of a license issued to him under the provisions of this Act. (2) No person shall consume Enguli. (3) No person shall export Enguli. THE ENGULI (MANUFACTURE AND LICENSING) ACT.* [Cap.96. 20th January, 1965.] It would be important to find out why the act is not enforced and whether the conditions for its formulation have changed and therefore, rendering it irrelevant. 2.1.10 The role of Education in the Treatment and Prevention of Alcoholism Both the educated and the less educated are prone to alcoholism and alcohol abuse. However, some research seems to suggest that exposure to the effects of alcohol on the body in schools may lessen its incidence (World health Report, 2001). A person with low education level is also likely to be less motivated to stop alcohol abuse due to the low socio-economic status associated with lack of or low levels of education. Research has established that, due to the threats of loss of jobs and social pressure to stop alcohol abuse, professionals, such as doctors and lawyers, tend to comply with treatment of chemical dependence and are likely to stay longer in a sober state (National Council on Alcohol abuse and Alcoholism, 2002). Countries like the United States of America and Canada, put substance abuse education in schools as part of the preventive strategy. A concerted effort by many public health organisations may with time enable society to readily identify early signs of problem drinking and encourage people to accept early intervention before the condition worsens. Many agencies in other countries like the United States seek to improve public understanding about alcoholism (Health Canada, 2003). 2.1.11 Community Participation in Prevention Programs Alcohol is often socially, economically and commercially available to minors. They may obtain it from parents, older peers, and merchants who sell to older minors. This relatively easy availability contributes in a significant way to underage drinking. Curtailing access to alcohol is one of the most effective ways of preventing underage drinking. Communities can address this in many ways: by promoting responsible adult behaviour, and holding adults responsible when they make alcohol available to minors. By increasing the price of beer, wine, and liquor, and by reducing the number of places where alcohol is sold or served, the community can protect itself against the social costs of alcoholism and alcohol abuse (WHO, 1994). It would be interesting to find out whether the community is concerned about controlling access to alcohol. Media and community education strategies that increase public awareness are crucial in soliciting community support. Prevention initiatives should also ideally target retailers, especially to encourage them not to sell alcohol to minors. Older peers and siblings who do not drink are also good role models (National Institute on Alcohol abuse and alcoholism, 22/06/2003, UNODC, 2003) The Community’s ability to observe and attribute problems to substance abuse is also a key factor in the prevention and willingness to participate in the prevention programs. The community would also be able to refer and support clients. (WHO, 2004). 2.1.12 Change of Norms and Behaviours Effective prevention initiatives use education to change societal norms and individual attitudes and behavior. Education efforts include school-based programs to change attitudes and enhance knowledge and skills. The media also plays a part (APHRU, 2003). In order to make successful prevention initiatives, mixed messages should be avoided. The same message should be delivered and coordinated through multiple channels:-the family, the media, community organizations, law enforcement, and health care providers. 2.1.12 Laws and Regulations Guiding Alcohol Existing laws and regulations should be consistently enforced. Broad community involvement and support has shown a reduction in underage drinking. When adults, parents, policy makers, and law enforcement officers signal their intent, it reduces alcohol abuse, especially among minors and those who provide them with alcohol. Public acceptance and political feasibility are of critical importance in selecting alcohol policies. The evidence for scope, seriousness and costs of alcohol related problems has to be stated and the public helped to appreciate the case for policy choice (WHO, 1995) It is worthwhile finding out opinions about the role of policy and community participation in the regulation of alcohol in Uganda. Social pressure from family, community, probation officers, and employers in combination with criminal justice has been found effective in coercing alcoholics to go for treatment as a prevention measure against mounting social problems linked to substance abuse/chemical dependence. These pressures are very important both to the prospective patient and to the community, since they form the contract under which treatment is given and evaluated (UNODC, 3003) Forced treatment for those who commit alcohol-induced crimes and personnel policies that compel alcoholic staff to go for treatment have been found to be a good preventive measure. Sometimes punishments have also been employed such as loss of a driving permit (WHO, 1995). 2.1.13 Education Programs in Schools Whatever your role is as educator-teacher, Principal, health educator, school nurse, coach, or guidance counselor, you can play an important role in preventing underage drinking. Children draw conclusions about alcohol use from what they see and hear about alcohol from friends, and classmates. Those who believe that alcohol use is a norm are likely to experiment with alcohol and become regular drinkers. When schools establish alcohol policies that clearly spell out expectations and penalties regarding alcohol use by students, they help reinforce the fact that underage drinking is not an acceptable form of behavior (Indiana University-Centre for Adolescence: Building an Effective Alcohol Prevention Program; 1996 Teacher Talk, 3 (3)). 2.1.14 Effectiveness of Interventions Numerous studies have indicated that brief interventions can be effective in changing the drinking behavior. This, however, works more with problem drinkers. During the brief intervention, a problem drinker meets with a health professional for one to four sessions lasting a few minutes to an hour. During this time, the medical professional makes the person aware that his/her current drinking patterns or medical problems are related to alcohol abuse and could progress to alcohol dependence. Brief interventions also have been used to motivate alcoholics to enter specialized treatment programs and work toward complete abstinence from alcohol (Wilcocks, 1992). 2.1.15 Conclusion The literature reviewed is largely based on the interventions elsewhere and does not provide much about Uganda in line with treatment and prevention programs. Although people have long known the problems associated with alcohol, limited effort has been put to address them from a multi-pronged perspective. New interventions have not been studied to assess the challenges and opportunities in alcohol programming. Cultural and socio-economic contexts in which alcoholism takes place may pose unique challenges although alcoholism as a disease can be universally conceptualized and diagnosed. CHAPTER THREE: METHODOLOGY 3.0 Introduction This chapter describes the methodology used in the study. The researcher describes the research design, data collection methods used, data analysis, the scope of the study, study area, sampling methods and respondent categories. 3.1 Research Design The research is an evaluative study using MTC alcohol program as a case study. This particular design was selected because the project chosen needed to be studied in detail and lessons drawn from it. The methods of Data collection were qualitative and the study was descriptive. The method was chosen because it enabled the researcher to capture a wide range of views about the study problem. The method provided for in-depth answers based on the respondents’ experiences and perceptions. 3.2 Study Area The study was conducted in Mukono Town council. Mukono Town has links to the English town Guildford. Mukono Town is bordered by Kalagi to the north, Kira Town to the west, Lake Victoria to the south and Lugazi to the east. It lies 27 kilometres (17 mi) east of the central business district of Kampala, Uganda's capital and largest city. The town occupies approximately 31.4 square kilometres (12.1 sq mi) of land area. The coordinates of the town of Mukono are: 00 21 36N, 32 45 00E (Latitude: 0.3600; Longitude: 32.7500). Mukono is one of Uganda's fastest growing urban areas. The 2002 national census estimated the population of the town at 46,506. In 2010, the Uganda Bureau of statistics estimated the population at about 57,400. Alcoholism is a major problem (Uganda Participatory Poverty Assessment Process, January 2000). Alcohol use is intertwined with the Baganda culture and household crude distillation is viewed as a source of income for poor households. Alcohol distillation is a women’s activity. The availability of alcohol at the household level makes it possible to abuse it and make it almost impossible to control the age of initiation to alcohol consumption. 3.3 Study Population The study population comprised individuals who were treated or were under treatment at the time of the study, individuals known to be alcoholic, persons involved in treatment (Counselors, medical and social workers) community leaders such as local council leaders, religious leaders, school teachers, the police, community development officers, probation and social welfare officers and the women who were involved in the sale and production of alcohol. The study also targeted professionals who work with alcoholics. This category of individuals was preferred in order to provide richness from different perceptions and experiences. The choice of the population also took cognizance of men and women in order to give the findings a gender balance and richness of perspectives. 3.4 Sample Size The sample size was 50 respondents. The number was arrived was deemed sufficient enough for diverse views considering the nature of in-depth interviews. The composition of the sample was 25 women and 25 men. The breakdown was considered in order to gather gender perspectives on the study. Respondents were categorized as medical workers (2 doctors and 6 nurses). The hospital had only two medical officers. Counselors (5). MKN employed five full time counselors who worked in the alcohol program. Community Psychosocial Assistants (3). The three assistants was the number directly under the alcohol program and these provided back up support to the MKN counselors. Community leaders (2 community development officers, 1 local council V chairperson (The district can only have one chairperson and he was considered a good source of information since he was key to allowing MKN run the program in the District), 5 local council III officials, 4 church leaders, 1 probation and social welfare officer and 3 teachers). The number of the community leader category was determined by different factors, for example the district had only two Community Development officers, One Probation and Social Welfare officer. The rest were selected on the mere basis on of their willingness to participate but also on considering that they had cooperated with the program in different ways such as referring alcoholics for intervention. 7 alcoholic patients were selected by MKN staff and comprised those who had make good recovery and those whose recovery had met a lot of challenges. 9 women brewers were those that were found brewing at the time of the reserach. The numbers were balanced between men and women in order to come up with balanced perspectives of the study. The researcher asked MKN staff to make appointments from the suggested categories with instruction to balance representation according to gender. The varying number of respondents from each category was based on the numbers available in each category. For example you can only get 1 Local Council 5 chairperson and then the district had 2 Doctors involved in daily clinical work. It must also be noted that the sampling method was purposive in that only those who were considered as vital in provided information were selected by MKN staff who had been approached to assist the researcher in mobilization of the respondents. 3.5 Sampling Procedure The sampling procedure was purposive. Individuals who could provide the required information were interviewed. The selection was based on the judgment that these individuals’ occupied positions of authority in the community and therefore important stakeholder, were directly affected by the problem, or contributed significantly to the problem under the study. The rest of the respondents were those who were directly working on the program. The staff of MTC was approached to assist in the mobilization of the respondents. The selection criteria was based on the perceived ability to provide the information required and the fact that the respondent lived in the study area. MTC staff had contact with the various categories of people through their community education as well as the treatment program. The knowledge of the community by MTC staff made it easy to get all the categories of respondents required for the study. Local leaders were equally easy to get due to MKN’s method of working with local leaders. Persons who were unwilling to participate in the study or were mentally or physically incapable of withstanding the interview were excluded. Table 1: Sampling Table Category Number Alcoholics 7 Police Officers 2 Medical doctors 2 Grade 3 Unit Health and hospital workers (nurses) 6 VCPA (Volunteer Psychosocial Assistants) 3 Women alcohol brewers 9 MKN Psychosocial Workers 5 Community Development Officers (CDOs) 2 Local Council V chairperson (LCV) 1 Local Council III Officials (LCIII) 5 Church Leaders 4 Probation and Social Welfare Officer 1 Teachers 3 Total number of respondent categories 50 3.6 Methods of Data Collection The methods comprised In-depth interviews. Key informants were purposively selected. Each category of respondents had questions tailored to their category (Community leaders, women alcohol brewers, alcoholic clients/patients, MTC field staff and Medical staff). Key informants were identified by MTC field staff from the category of alcoholic clients/patients (7), Community leaders (2 Police Officers, 2 Community Development Officers, I Local Council V Chairperson, 5 Local Council III official, 4 Church Leaders, 1 Probation and Social Welfare Officer and three teachers), medical staff (2 medical doctors, 6 health workers within the hospital and health units), women brewers (9) (Cf. sampling procedure). 3.7 Procedure for Data collection The researcher got a letter of introduction from the University and sought permission from MTC to use their project sight for the study. MTC staff was given the categories for the various types of key informants. The MTC field staff made contacts with the respondents and made appointments for the interviews. In depth interviews were conducted with the various categories of respondents using interview guides. Key informants were interviewed and their responses were recorded in detail. The sample which was purposively selected gave a wide range of perspectives and respondents were encouraged to give suggestions and recommendations on how to deal with the problem of alcoholism. 3.8 Data Management and Analysis After collecting the data, the researcher developed a code book where responses of the same themes and to the same questions were assembled (systematic coding and tallying). Contents of the code book matrix developed were compiled, interpreted and analyzed using a Strengths, Weakness Opportunities and Constraints (SWOC) method of analysis. This particular method was effective for the evaluative design. It enabled the researcher to critically look at the programs strengths, weakness, opportunities and constraints. The research findings were then put into a logical flow for presentation. The method used enabled the researcher to obtain the objectives of the study. 3.9 Methodological and Practical Limitations of the Study The findings may not be generalized for Mukono District due to socio-cultural, political and historical differences in various regions of the county. Mukono seems to have contexts for interest in this research and these are conflict situations, post conflict situations and relatively peaceful situations. All these may bring about variations in alcohol abuse. Some districts, for example, Banyala in Nakifuma is predominantly Moslem and this may have unique aspects in alcoholism. Generalizing findings to the whole country may not be justifiable although the study brings about important issues. However, as a solution to this limitation, the researcher recommends similar research in other areas of the country for comparison. Time was a constraining factor. The research area was distant and located in the areas of active conflict. This researcher had to travel by Taxi and Boda Boda’s. This meant a tight schedule although it had no significant implications on the out comes. The assistance accorded by MTC staff countered the negative effects of time limitation. Weather change rendered some areas inaccessible or difficult to access. During the time of the research, it was a rainy season and most areas were slippery and difficult to access. However, the researcher was patient and made sure that the areas that were of importance to research were accessed using a motor bike. And where it was impossible, the researcher, with the help of MTC staff, sought alternative respondents. 3.10 Ethical considerations The researcher sought informed consent from the respondents. During the interview, the researcher also ensured confidentiality by carrying out the interviews in private areas and also by ensuring that responses were not tagged to the respondent. Persons who were found to have profound physical, psychological and social problems were referred to the hospital and MKN social workers for management and support. Interviewees were also made to understand that they were not obliged to answer all the questions if they felt uncomfortable and they also were made to understand that they could terminate the interview or asked for clarification. CHAPTER FOUR: STUDY FINDINGS 4.0 Introduction In this chapter, a full account of the findings and their implications on prevention of the causes of alcoholism and alcohol abuse is presented. Major issues arising out the findings are debated upon. The discussion is put under major themes and study objectives. This section presents detailed assessment of the alcohol program activities, reactions of the beneficiaries to the alcohol program and the constraints faced and opportunities for alcohol programming. 4.1 Activities Carried out by MTC in the Prevention and Treatment of Alcoholism MTC carries out various activities in the prevention and treatment of alcoholism program. The activities range from community education, capacity building, treatment and prevention of alcoholism. 4.1.1 Community Education and Capacity Building This activity involves community sensitization which involves information on how to access treatment and short workshops on the problem of alcoholism, capacity building of key stakeholders and partners on how to integrate alcohol programs in their activities, Education and Communication material development. Asked to describe what activities were carried out by MTC, a Psychosocial Worker had this to say: In community education, we carry out a number of activities such as training of local councils and members of local organizations, we also produce posters for the communities and we also tell them about the disease concept of alcoholism” (MTC social Worker). i) Community Education MTC uses a community-based approach in preventing alcoholism. Communities are mobilized, using a network of volunteers, religious leaders and local councils. Communities are invited in an informal setting, for example under a village tree, and then the counselor leads a discussion, the community contributes ideas in the discussion and then the counselor or the psychosocial worker fills in knowledge gaps. Community education being a process, it may take several sensitization sessions lasting 1-3 hrs. Nevertheless, the process yielded results as evidenced in the following quotation: We mobilize communities in informal settings and sensitise them on the dangers of alcohol. As a result some communities have begun formulating their own laws on how to control alcohol abuse; others come to us for help (MKN Psychosocial Worker). The approach of community education seems cheaper than the hotel based workshops and had several advantages:- a) Being in the community setting, it is less intimidating and non discriminatory. Participants do not need invitation letters. b) The approach targeted community based people who can have greater influence on the program outcomes. c) There is no transport costs involved since participants were within their community setting. d) The approach also removes the possibility of favouring certain categories of persons for the real or perceived benefits of hotel based trainings. e) It promotes dialogue and community engagement in problem solving. The approach gives the opportunity to discuss some of the myths that surround alcohol use and gave the community a chance to reflect on the effects of alcoholism. Communities learn new knowledge about alcoholism. The evidence of the learning process is reflected by the willingness to recommend persons for treatment. The following quotation summarizes the role of the education activity; We get our clients through community education, referral through family, community health units, spouses, community and local council leaders. It is just about the dangers and after explanation, others realize to be victims. (MTC social Councilor). MTC contributes some amount of money for the day’s meals and the community contributes labor, utensils and when there was food in the community, they also contribute. These community education workshops last a few hours and are repeated over and over to cover as much as possible. Using a few hours at a time enables the community to maintain interest and have a considerable knowledge base build up. This approach shows community ownership and involvement. Using a few hours at a time does not lay a big burden on the community by spending hours of the members’ time for doing other demanding activities. This method of work seemes to suit good practice in community based work whereby community members are viewed as partners in problem solving. About community contribution, a MTC field staff had this to say. MTC gives 20000 thousand shillings to the community participants, the community brings fire wood and other things to use for cooking, they use the money to buy what they do not have, they are most times willing to contribute (MTC social Worker). This quotation brings out key opportunities that resulted from community sensitization and indicates that communities are more willing to utilize the service the moment they know about its existence. Although community education presents as a key success, staff is of the view that there is need to do more by increasing the resources needed to carry out education in a wider community. Some of the women brewers interviewed said that they had heard about the education program but their area had not been covered by the MTC staff. Asked what she had to say about the education program, a woman alcohol producer said I have heard about MTC but have not attended their education because they have not come to my location (a woman brewer). When asked about the education program, a MTC area program officer had this to comment. MTC received only 30,000 dollars for the alcohol program and yet the problem needs much more resources, this limits the amount of work we can do in the program” (MTC Area Program Officer). The education activity also lacks a participatory process of making community action plans. It is my view that it should be at these meeting that the Psychosocial Workers engages the community to come up with what they can do to contribute to the reduction of the problem and offer social support to those who sought treatment but with no protective social networks. This shortfall limits the degree to which community participation can go. Although there were no joint community work plans, there was evidence that the communities had begun putting up bye-laws to deal with alcohol induced problems as shall be discussed in the section on community reactions and opportunities for alcohol programming. However, assessing the community education activities, one realizes that it is a very important component in alcohol programming and should take up more resources and effort in order to achieve greater results/treatment and prevention outcomes. The people trained by the program should be enabled to cover bigger areas given the fact that MTC has a few social workers who cannot factually cover all the areas. MTC built the capacity of some key community leaders (150 people in 2003) (MTC activity report, 2004) but did not consider how they could have facilitated them to put their knowledge and skills into practice. This to me is a major limitation in the education component of the program although some district persons reported having used the skill and knowledge in their work. There is no evidence to suggest that MTC uses the opportunity from community education to extend to cover those who opt for treatment but sight lack of basics for hospitalization as a major cause of unsuccessful treatment outcomes. The community is not engaged in supporting those who had alcohol problems and wanted treatment. During sensitization meetings, MTC could take as an opportunity to get the community to materially support its members who choose to go for treatment. The district leadership could be a major partner in this crucial support. When asked to comment on the community support, an alcoholic client responded: When I was in hospital, no one cared for me, I became very hungry and decided to run away from treatment, I need to be helped I know that I am a nuisance in the community, if you had found me drunk I would not have respected you. (an alcoholic client). The major benefit to the program is that it is within these workshops that MTC gets its clients directly or through a community referral system. To stress this important benefit of the community sensitization aspect, a MTC counselor expressed that: We get our clients through community education, referral through family, community health units, spouses, community and local council leaders. (MTC Counselor). The messages carried to communities are mainly about the dangers of alcohol abuse and also about the available services to those suffering from the problem. When asked about the messages given, a MTC field worker had this to say: … It is just after about the dangers and after explanation others realize to be victims and they come out to seek help, to be assisted to remain sober others were through friends who advise them to come (MTC Psychosocial Worker). From the above quotation, one realizes that community education provided essential information for one to start seeking help. Some of the participants in the sessions also acted as agents in letting those who had the problem know that there was help available. This have multiplies the number of helpers in information dissemination. ii) Production of Alcohol Related Information, Education and Communication Materials There is not much literature produced in Uganda that offers comprehensive alcohol education in Uganda. The available literature is produced elsewhere. In order to provide some literature, MTC had produced posters on the effects of alcohol on the body and worked on two books. One of the books is a training manual and other book is a handbook for educators, alcoholic patients, health workers, counselors and other individuals wishing to learn about alcoholism, its treatment and prevention. The materials produced were all in English. This had limitations considering the fact that the majority of the community spoke the local language (Luganda). The materials were not in sufficient numbers to cover a wide range of clientele. Posters that were in English could be seen in some parts of the district but were also written in English thereby limiting community understanding. Translation of the materials into the local language could have made it easier for the materials to be understood. Nevertheless, the materials developed provided a big resource to the community, especially, those who could read and write. The poster highlighted in pictorial form how devastating alcohol can be to the body. Moving around some shops, hotels, schools and health units, one could observe some posters hanging in these areas. The copies of the prevention and treatment handbook were also available in health units. iii) Capacity Building of Stakeholders MKN trained and provides support supervision to a number of stakeholders in the district that included Community Based organizations, health services department and various local government departments. Records available in the MTC 2004 report indicate that 150 persons were trained in alcohol treatment and prevention (MTC activity report, 2004). These were targeted in order to create some level of sustainability of the program when MTC would eventually leave (MTC philosophy of work 1998). Individuals from the health department were trained in detoxification and basic helping skills to enable them offer services to chemically dependent individuals and their families. Representatives of different government departments, such as education and community development and probation and social welfare were trained to offer alcohol education and in basic helping skills. Representatives of NGOs and Community Based Organizations were also trained to carry out alcohol education, offer limited counseling and to mainstream alcohol education in their programs. The capacity building activity has a number of benefits especially towards building a disease model of alcoholism aimed at increasing efforts to deal with the problem and also to solicit institutional support to the program. Politicians who access MTC capacity building services express a level of confidence in knowledge and skills in the field of alcoholism. The gained new approach to addressing alcoholism made it easier to engage communities without angering the members and provoking resistance. Before MTC started educating us and the community about the dangers of alcohol, it was very difficult to talk about alcohol in our political activities with the communities, but now whenever I meet the community I talk about alcohol and the community does not mind much as before. (Local Council 5 –LC5– leader). Activities are apparently appreciated by the community in the area, including politicians. The appreciation is demonstrated by willingness to carry on the message to others among other things. From the above quotations from some respondents, one observes that MTC works towards a solution to the problem of alcoholism in Moyo district while taking into consideration that no one agency can do it alone without major stakeholders such government departments (health, local government) and other NGOs/CBOs. At the time of the research, it was discovered that the few staff with knowledge and skill to treat alcoholism were constantly shifted to other sections of the hospital due to shortage of staff in the hospital. MTC in its planning had not foreseen this problem. MTC had assumed that the staff who received capacity building services from MTC would be devoted to the detoxification unit and other alcohol related services. This scenario could have been averted by building the capacity of as many medical staff as was possible. However, resource constraints could have prompted MTC to arrive at such an assumption. One major problem we have is that we have to work in other wards and this limits our contact with the alcoholic patients (Nurse-MKN Health Hospital) A MKN field staff expressed the same problem: MTC built the capacity of some medical staff to run the treatment unit, but now this staff has been allocated to other wards and one of them has been transferred from the hospital to a health unit, this is very disappointing (MTC Area Program Officer). This problem can also be attributed to competing health needs and understandably the district finds itself having to make a choice between putting the scarce resources on alcoholism and other major health issues. This finding is in line with what Todd, 1882 (in Milam and Ketcham, 1988) said that every human being is worth saving but if a choice is to be made, drunkards are about the last class to be taken care of. Lack of proper diagnosis and epidemiological data on alcoholism made it difficult to rank alcoholism as a disease afflicting big sections of the community and therefore worth putting the scarce resources into it. This is not however, to say that the district puts no resources into the alcohol program. 4.1.2 Care and Support MTC carries out a number of activities in order to increase care and support to the individuals and families affected by alcoholism. Care and support is mainly in terms of psychosocial and medical and less of material provision. This is not without implications as will be discussed later in this section. The components of care and support include psychosocial support with the following elements: motivational counseling, referral, follow up and facilitation of formation of support groups; medical care which involves detoxification and treatment of mental health and physical complications. 4.1.2.1 Psychosocial Support i) Motivational counseling One of the most unfortunate realities of alcohol abuse is chemical dependency, a condition whereby a person develops a compulsion and obsession to alcohol and actually functions physically only in a presence of a given alcohol concentration in the blood (Milam and Ketcham, 1988, Ketcham and Asbury, 2000). The person’s social life begins to revolve around looking for and drinking alcohol (Bio-psychosocial dependency on a mood altering substance). MTC psychosocial workers seek and motivate chemically dependent individuals (individuals addicted to alcohol and other substances) to go for medical detoxification and treatment of associated conditions. MTC, in collaboration with Moyo hospital, established a detoxification unit within the hospital that offers specialized attention to patients with alcoholism. Findings indicate that although MTC staff was often successful in motivating alcoholics to agree to go for treatment, the distances they had to cover to access detoxification and other medical care services made it impossible for some to go. MTC did not have a provision for supporting this and so many never made it to the treatment facility in Moyo district hospital. One of the community psychosocial assistants had this to say about motivating alcoholics: We get many people who want to go for treatment but then Nakifuma is very far and many of these patients are not able to go Nakifuma This points out a major bottle neck and leads back to lack of adequate resources to the program. MTC should work with the district to see if there are resources available in lower health units to offer limited services or convince the district to offer transport to those willing to go for treatment. However, from problems faced at the main hospital, it could have been very difficult to adapt and implement such a model. Motivational counseling also involves working with alcoholics to keep in treatment and comply with treatment procedures. MTC and the trained medical workers play the role of motivational counsellors. ii) Referral MTC staff after motivating alcoholics refers them to Health Centre II hospital detoxification unit or to the nearest health unit which then makes referrals to Health Centre IV hospital. Respondents also said that MTC referred them to Kampala to join AA experienced Alcoholic Anonymous groups. Referrals are also done by the community members who had had contact with MTC education activities. Some of the alcoholic would go directly to the hospital but this was not usually the best as some would receive negative reception at the out-patient department. It seems to the researcher that all the staff at MKN Health hospital was not aware of the referral system and would be surprised to see a “drunk” coming to seek admission. Persons who go to the hospital came with some level of intoxication due to the fact that withdrawal symptoms associated with drop in blood-alcohol concentration in chemically dependent person made impossible to reach the hospital in sober state. Nurses who are not familiar with addiction do not understand why someone would come to hospital for admission in a state of intoxication. This pointed to some loopholes in the project set up especially on involving and seeking support of the entire hospital staff through their leadership structures. I was not treated well by the nurse; she told me that if I am drunk I should go home and rest.¬ (An alcoholic client). The unit being in Mukono town also presents questions of accessibility by the poor who live in distant sub-counties within the district. The following quotation summarizes the difficulties faced by MKN staff in performing the activity of referring clients to the detoxification unit. Distance seems to put a strain on accessibility of the service. The unavailability of detox unit within the community makes it difficult for VCPAs to refer such clients to Mukono Health Centre IV hospital where the detoxification unit is, secondly they complain of lack of support from other family members. (MTC counselor). Alcoholic patients are usually poor and in some cases lack family support system due to the nature of the disease that causes the family to be disgusted with the patient due to the alcoholic personality. Asking such a patient to go to the unit miles a way poses serious challenges. MTC counselors and Volunteers as well as clients who had been in treatment expressed the problem of referring people without family commitment to supporting them. Alcoholism does not only affect the individual but also the entire family and community and therefore all these should be involved in the treatment process (WHO, 1994, Al-Anon Family Groups, 1981) This affects outcomes as shall be discussed in more detail in the later sections. While designing the project, MTC seemed to have under estimated the impact distance and lack of family support would have on the accessibility of the service. This will be further explored in the discussion on constraints to the program. Although the Ministry of Health mental health department had begun the process of making mental health care available at the lowest health centre units (II and III), MTC had not fully utilised this to lobby for treatment services for alcoholism at these levels. The referral choice is therefore, severely limited to one choice which proves very expensive for most community members. iii) Follow up and Support Group Formation Depending on the level of severity, MTC psychosocial workers offer home based counseling to individual alcoholic patients and their families or within the detoxification unit and later make follow-ups after discharge to minimize relapse. However, due to limited financial and human resources, this activity experienced severe limitation and could have been a factor in relapsing clients. “Sometimes we do not do follow-ups due to fuel problems” (MKN Health Centre IV Counselor). Follow up of clients requires a lot of resources and time. Considering the limitations faced in terms of resources, the treatment outcomes become affected. Group work formation could have been appropriate. However, the group work strategy employed by MTC to increase peer support also face limitations due to its contextual complexities. The way AA is principled seemed not to favour resource limited settings because it does not accept income generation and outsourcing of material support (Alcoholics Anonymous 1997). Most of the clients interviewed expressed the need to combine treatment with “employment opportunities”. Recovering alcoholics need to be engaged in counseling groups that involve income generation as well as opportunities for peer support. This is in line with good practices in treatment and rehabilitation (UNODC 2003). MTC counseling strategy did not incorporate economic rehabilitation. This limitation is discussed in some detail in the later section on constraints. 4.1.2.2 Medical Treatment Together with the medical staff in Mukono Health Centre hospital, MTC psychosocial workers provide motivational, emotional and counseling support to the alcoholic patients in the unit. The medical staff in the unit provide support to patients to deal with complications that arose from the withdrawal symptoms and physical complications. By time of the research, available records in the hospital indicated that 40 patients had received treatment in the unit. The inclusion of medical treatment in the program indicates that MTC recognizes the long term effects of toxicity, malnutrition and hypoglycemia, and even the withdrawal symptoms in causing or aggravating the alcoholic’s psychosocial problems. There were however, problems in the medical aspect of the program. The competition for resources with major health problems such as malaria, river blindness and AIDS which MKN does not focus on seemed to have complicated the problems of allocating resources to medical treatment of alcoholism. For example, at times when there would be no alcoholic patients in the detoxification unit, the unit would be occupied by river blindness patients and sometimes the alcoholic patients would be put in the general ward to give room to river blindness patients. Putting alcoholics in the same ward as general patients is contrary to the good procedures for treatment of alcoholism (Milam and Ketcham, 1988). The lay out of detoxification units is different from regular wards to minimize the reoccurrence of hallucinations. The findings indicated that although the hospital provided the facility, the initially trained medical staff was constantly shifted to the general ward thereby compromising the quality of care in the detoxification unit. To bring this problem out, one trained nurse had this to say There were six of us trained to handle alcoholism, one staff died and another one was transferred to another health unit, we are assigned to work in other wards and other nurses who were not trained go the unit, sometimes alcoholic patients are put in the general ward (A nurse-Mukono Health Centre IV Hospital). Putting alcoholic patients in the general ward is not recommended in best practice. Detoxification units have specifications that are not in the general ward (Baron and Soren, 2001). Most major hospitals in the developed world have independent units for treatment of alcoholism (Hezeldon, 2000). Due to limited resources MTC seems incapacitated to build the capacity at the lowest levels in order to make treatment services available near the community. This will be discussed in more detail later in the section on constraints to the program. Not withstanding the constraints discussed above, the detoxification unit did help some clients to recover and provides a breakthrough towards addressing one of the major social and health problems in the district. The unit also provides an insight into the fact that alcoholism is a disease that requires a medical intervention among other interventions. The issue of highlighting alcoholism as a disease stood out in the research. Ketcham and Asbury, (2000:141) also point to the benefits of understanding alcoholism as a disease with hereditary and biochemical foundations 4.2 Reaction of the Community on Treatment and Prevention of Alcoholism This section gives an overview of the reactions by stakeholders about the alcohol treatment and prevention program. Reactions here are discussed because they portray attitudes that can either promote the alcohol program or render it irrelevant and difficult to implement. The reactions cover responses to specific questions as well as the actions done as a response by stakeholders to the alcohol program. 4.2.1 Reaction to the View that Alcoholism is a Disease When respondents were asked their views about the message carried by MTC that alcoholism is a primary disease, the idea elicited mixed reactions. There were marked differences between medical workers with the exception of those who received alcohol training by MTC and rest of the stakeholders interviewed. Community leaders, alcoholics, police officers and women brewers used a social function, signs and symptoms argument to justify their belief in the disease concept of alcoholism. The following quotations show some of the reasons advanced by the stakeholders in support of the disease concept: It is a disease and I am an example of the disease, if something prevents you from functioning normally is it not a disease (an alcoholic client). I am example of the disease, I have seen it with my own eyes, it is very dangerous disease. It affects social functioning (an alcoholic client). It is a disease because like any other disease, it causes symptoms and signs. Prevention and treatment measures are also there. It kills, if untreated, like any other disease. Any thing that destroys your life is a disease (an alcoholic client). Alcoholic patients used their personal experiences with alcoholism and their attempts to stop alcohol without medical and psychosocial help that were futile to interpret and acknowledge alcoholism as a disease. Some community members especially also argued in support of the disease concept as evidenced in the following citation: Yes alcoholism is a disease because once you are addicted, you lose control over your life, one becomes irresponsible and physical problems become the order of the day, one becomes a public nuisance (Police Officer). A local council official also asserted: Indeed MTC has proved to me that it is a disease. Being in contact with this kind of people, I am more than convinced that it is a disease because the person cannot faction well in society (Local council official). Those who argued against the disease concept had reasons linked to deliberate excessive use of alcohol leading to bio-psychosocial complications. They argued that when one abuses alcohol, then the person gets alcohol related problems. The view pointed to a moral perspective of alcoholism. Some examples of such views are: I do not think it is a primary disease. It is a habit what I take as a disease is what comes out of the habit, someone will get complications (Medical doctor). The view of the medical doctor contradicts scientific studies that link alcoholism to genetic vulnerability as well as neurological set up in certain individuals. Neurotransmitters and brain amines play significant role in determining who becomes easily addicted and who does not (AA 1987, Ketcham and Asbury, 2000, Milam and Ketcham, 1988). The differences in responses to the question as to whether alcoholism is disease or not could have been due to the exposure to MTC education campaigns that targets alcoholic patients and village communities. Some respondents such as alcoholics could also have used their personal experiences of the problem. The medical staff could have responded using personal opinions or knowledge given to them in the medical schools. Whatever the views held, it had implication on the alcohol prevention and treatment program. These opinions either motivated or de-motivated individuals to deal with alcoholism or support the program. 4.2.2 Community Support for the Program The study sought to understand the existing support to the alcohol treatment and prevention program. When respondents were asked about what they thought about the program, they gave various answers to the question. Representatives of institutions such as churches and schools, community leaders such local council officials and individuals interviewed, expressed appreciation and support for the program. They viewed alcoholism as a big problems needing continued intervention Families, village community leaders interviewed said they supported the program in terms of referring patients for treatment, attending workshops and sensitization seminars, education of communities, attempts to set up bye-laws in a participatory manner and talking well about MKN in political gatherings. The community is also advocating setting up detoxification facilities within health centre III facilities. A local council official had this to say This program is very good to us, we have mobilized our people to set community regulations on the use of alcohol, we encourage people to drink after work, and this decision was reached at by the whole community (Local council official). However, on whether the district leadership had reacted to the program by extending financial input into the program, all community leaders interviewed said this had not been done. This could be attributed to the fact that there are other competing needs that are perceived as more important coupled with the poor revenue base and dependence on the central government that has not yet come to terms with the reality of the alcohol problem. Some leaders also complained of not being consulted in the budget making process. We have not allocated resources. We have been having problems and budgets are discussed without my input. I hope this time we shall include something (Local council IV chairman). The above quotation highlights problems of sidelining some crucial departmental leaders in budget preparation who would otherwise sight some key community development problems of a social nature that need resource allocation. 4.2.3 Participation in the Alcohol Education Program This section discusses community participation in the education program as a form of response to the program, what the community thinks about the education program and what the community recommends for the education program: i) Request for more Education Opportunities Various categories of respondents expressed need for more education about the dangers of alcohol abuse. This they hoped would help individuals reduce the rate and amount of alcohol used. The following quotations highlight how the community has reacted to the program: Alcoholism should be stopped, people should come up as in the case of AIDS program by talking to people through workshops, meetings……… (Teacher). This reaction is in line with the recommendation of World Health Organisation, though there is a caution that education alone may not have tangible results without other measures such as legislation, treatment and prevention (WHO, 1995). Lack of legislation or policy on alcohol may counter the gains of education. ii) Attending Community Workshops The community supports the program through attending workshops usually organized under informal settings such as under trees and community physical structures such as church building and schools. Records available in MTC offices show that an average of 80 (MTC workshop attendance lists) people attended the workshops per week per counselor. Continued education and sensitization has reportedly reduced the stigma attached to being alcohol dependent. This is in line with what most addiction treatment and prevention experts say about action towards alcohol. For example, Ketcham and Milam, (1988:10) argued that sensitization about the disease concept of alcoholism offers for the explanation that has, until now, eluded explanation. Education provides the capacity to separate myths from reality and stigma is usually shrouded in mystery and myths. iii) Benefits of the Education Program Asked to comment on the fruits of sensitization, a volunteer psychosocial assistant had this to say: The community has a positive attitude. They want members who have alcohol problems to be helped (VCPA). People expressed that they had heard about the program run by MTC and some wondered why MTC was not covering their villages. This indicated that some community members thought that MTC should be making a wider coverage. I have heard about MTC but I have not attended their education because they have not come to my location (a woman brewer). The above quotation points to the fact that there was a need to increase resources towards the sensitization program. However, on the other hand, increasing sensitization without marching numbers of trained medical personnel and decentralization of the detoxification services to the lower health centres could lead to increased frustration among those who would seek treatment services as was already the case. Not withstanding the weaknesses presented in the sensitization program, the efforts had some degree of success implicit in the demand for more sensitization opportunities. There was also some evidence that some people had taken it upon themselves to sensitise others on dangers of alcohol. For example a local council official told the researcher Whenever I go to public functions such as burials, I give a few minutes on the dangers of alcohol; the program has made it easy for us to do it now (Local Council 5 official). iv) Community Recommendation on the Education Program Having seen some examples of individuals who have been helped out of the addictive disease, the community feels that the program should continue. The following are some of the recommendations made during the interview: The community feels that the program should continue and more funding should be provided by donor agencies because the program is helping some alcoholics to recover and become useful people (Local Council 5 Chairperson). My comment is that we need to create awareness at parish and village level, we need to put counseling centres for those who are alcoholic……..” (Local Council 3 leader). 4.2.4 Responses on Controlling Alcohol Production and Consumption The question on controlling alcohol production and consumption brought about a number of issues as discussed below: During the research, some respondents, including political leaders and law enforcement agents expressed the view that alcohol production at household level is an economic activity that allows women to do other household duties while distilling or brewing alcohol. The implications of this will be discussed while talking about challenges faced in treating and preventing alcoholism. Lack of opportunities, especially for women, leads to increased availability and production of crude alcohol distillates in Nakifuma whose toxic content has not been fully analysed. In response to the question on controlling alcohol, a Local council III official had this to remark: The reaction of women towards stopping alcohol production in homes is so bad. It is not in their interest to stop. The women feel that alcohol production keeps them within the household to allow them to carry out other domestic chores (Local Council 3 leader). As indicated above, it would be an uphill task to convince the community to stop home based alcohol crude distillations without addressing some of the crucial gender challenges. Women in the Nakifuma community take on a double role of taking care of the children as well as generation of income for the family. Lack of alternative income generation opportunities for women makes it easier for them to engage in alcohol production. During the interviews however, it was surprising to the researcher that most of the women brewers interviewed (7out of 9 interviewed), brewed because they had to take care of the family because the husbands were alcoholic. For our husbands who drink much, we have little control. When we tell them to stop it, it is like pouring cold water on a hot metal. I have totally failed to control my husband. The suffering at home is a result of his drinking, we cannot plan jointly, I am the only one planning (a woman brewer). Most (6 out of 9) also had someone with an alcohol problem within their family and directly asked for MTC intervention. My son has big a drinking problem, how can MTC help me deal with this problem? (a woman brewer). What was viewed in positive light by community leaders was negated by the very women they purported to speak for. The following quotation highlights this apparent contradiction. We would like to be assisted to do alternative income generation, due to smoke and heavy work involved in preparation of alcohol, my chest sounds like an empty drum, how can I like what I do? (a woman brewer). The women did not see alcohol brewing as an easy way of making a “one stop shopping centre” but a desperate move to generate income for the family neglected by alcoholic husbands. This is not to down play the general lack of opportunities. One may draw a conclusion that home based production of alcohol was causing more problems than solutions. Women who are the producers seemed more ready to give up the practice if there were alternative opportunities for income generation. This will be further explored in the section on the recommendations. During the interview there was a feeling that the program was good because alcohol is viewed as contributing to retarded socio-economic development, many broken homes, deaths, exposure to HIV infection, increased crime and dropping out of school. Local council five chairperson gave the following remark Excessive use of alcohol is causing a lot of problems in our community, some people do not work, some people have died and there are also a lot of domestic problems related to alcoholism (Local Council 3 chairperson). This is in line with the World Health Organisation (WHO) warning on alcohol abuse The level of alcohol consumption of a population as a whole is significantly related to the level of alcohol-related problems which that population will experience (WH0, 1995:3). WHO goes on to warn that, within the abstract listings, lie varieties of ill-health, unhappiness, loss, pain, deprivation, denial of self, family disruption, wounds to others and destruction (WHO, 1995). For example, during the time of the research, a local council driver suspected to have been drunk overturned a dumper truck carrying mourners and caused death to more than 10 people and severe injuries to the others. Although there is general consensus that alcohol consumption caused a lot of problems, reaction to controlling it contradicts the negative view of alcohol consumption. This could be linked to high poverty levels in the district as well as well political reluctance to enforce the law for fear of being voted out. The political system of electing community leaders rather appointing them on the basis of qualification makes it almost impossible to enforce social legislation that would be seen in bad light by the community. This problem is further explored in the discussion below. Community leaders expressed that government lacked commitment in dealing with the alcohol problem despite all the obvious alcohol related problems. This sentiment was expressed in the following quotation from a catholic catechist. The government should be fully involved with other NGOs who are interested in carrying out these activities. Because alcoholism is not only an individual problem but a national issue, the government should put resources to create awareness and to treat this kind of people (a Catholic catechist). On close analysis, the 1965 legislation (Willis, 2007) against crude distillations has become largely dysfunctional due to partly the political turmoil in Uganda that led to significant social disintegration and a culture of lack of rule of law that permeates to the lowest level of society. Reintroducing or reinforcing this particular piece of legislation may lead to significant political sentiments. The community uses its voting power to blackmail whoever wants to stop alcohol consumption and production. So it has actually become intertwined with politics and this same political ramification was expressed by the police officer during the interview. When we try to do something about alcohol politicians come in to frustrate our efforts the main challenge is weak laws and political interference in the work of police (Police officer). The relationship between alcohol control and politics was expressed by various respondents including political leaders themselves: This is also in line with what Willis (2007) points out in his article Clean spirit. Community leaders fear to control alcohol for fear of being removed from office, one leader was removed from office because he came out strongly against alcohol (Local Council 5 Official). Due to the political nature alcoholism has now assumed, some respondents thought that government policy on alcohol encourages home production of alcohol. Alcohol producing companies come here with loud music and distribute free alcohol samples even to children; it seems the policy of government is to promote alcohol production (Local council 5 official). The argument was based on the silence about the problems and the advertising of strong gins using mobile trucks with loud music by alcohol producing companies who allegedly supply alcohol samples to minors. Crude distillates that are known to contain toxins, such as, methanol are produced from other regions in the country and brought into the area with impunity and sometimes with outright political interference as alleged by some respondents. The respondents view this as one of the most serious problems and want government to take action against it. For example one pastor remarked: Government should stop distribution of crude distillates from other parts of the country it seems that some powerful politicians are involved (Local council 5 official). From the discussion above and the sighted quotations, the control of alcohol consumption and production possesses a major challenge and one can only hope that the government will one day take a strong lead in combating the alcohol problem which is threatening to overwhelm the country. The leaders that were willing to control alcohol abuse were caught in the policy gaps that made them fear for their future political carrier and in some instances ended up being compromised. 4.3 Challenges in Carrying out the Alcohol Program This section presents an analysis of the challenges faced by MTC in carrying out the alcohol program according to MTC staff and stakeholders. In this section challenges will be discussed from within MTC and the community. The main challenges identified were perception about alcoholism, capacity of the medical staff to diagnose and treat the disease, reception of patients at the out-patient unit, quality of care, stigma, nature of the disease, lack of social support networks, program content, accessibility of the detoxification services, insufficient funds, lack of government commitment, political interference, community attitude towards drinking and women’s poverty. These limitations are discussed in detail below. 4.3.1 Perception about Alcoholism Lack of consensus about what alcoholism is among medical, community members and MTC staff was a limitation to the program. This lack of consensus has some negative consequences to the program. The following quotations from medical doctors and nurses serve to explain this scenario. It is caused by social problems not a disease, a person becomes addicted (Medical doctor Mukono Health Centre II Hospital). I consider alcoholism as a habit. It is you making yourself to drink, because if you do not want to you can leave it (Female Nurse Mukono Health hospital). This perception contradicts MTC’s official model that looks at alcoholism as a bio-psychosocial condition. Perception about alcoholism plays an important part in the direction of resources to the problem. Implementation and outcomes of the program are dependent upon the direction of perception. For example, if alcoholism is perceived as the problem of the psychologically weak and the irresponsible, this value judgment affects empathy towards the victims and their families. Whatever the direction, whether positive or negative, perception has bearing on treatment and prevention of alcoholism. There was no consensus on perspectives on the concept of alcoholism. Medical staff trained by MTC held a similar perception and appreciation of alcoholism as a disease. The following quotation explains this; I consider alcoholism as a primary disease because people come with the problems and on average I see 5-6 people per month (Nurse in Eseri Hospital). The differences in perception seem to stem from the training received from the medical schools as well as the from ongoing staff training courses. Nevertheless, the perception on alcoholism had bearing on the treatment procedures for example, MTC had to constantly remind the staff that alcoholism treatment needed a unique approach and that patients needed a separate unit with specific layout. There was also a level of stigma (discussed on the subsection of stigma) leveled against alcoholic patients by some medical staff members as well as outright misdiagnosis of alcoholism. For example people who came to the hospital with alcohol induced injuries were not diagnosed although according to some medical staff continued to abuse alcohol if in the admission wards. The following quotation confirms the above finding. Sometimes patients who are admitted in the surgical ward with injuries such as fractured legs drink from the wards and become a nuisance, the other patients complain to us ¬(Nurse Eseri Hospital). The problems faced by the alcoholic patients (as MTC calls them following some aspects of Alcoholics Anonymous (AA) where one has to admit that he is an alcoholic, a program used in combination with the medical model) in the hospital seem to have confused some who would have been motivated by MTC staff to seek medical treatment on grounds that they suffered from a disease only to be faced with some level of hostility from those that were supposed to treat them. To demonstrate this hostility, one psychiatric nurse remarked: When persons with alcohol problems come to the outpatient clinic, they send them way saying “go to the mental health clinic” something they do not like to be told because they do not consider themselves as mental health patients (Psychiatric nurse Eseri Hospital Mukono). This implies that MTC should have done more with the medical staff before starting the program. Some preparation and negotiations with the district leadership, the district director of health services and the medical superintendent were done prior to starting the program but these were not sufficient. Limited funding to the project could have been a major limitation to wide ranging consultations. This limitation is discussed in some detail in the subsection below. 4.3.2 Inadequate Capacity to Diagnose and Effectively Treat Alcoholism Treatment of alcoholism is a specialized area generally referred to as “addictionology”. (Ketcham, 2000) Some countries like the United States have special programs to train medical staff in dealing with addiction to alcohol and drugs. This does not seem to be the case in Uganda, although Butabika Mental National Referral Hospital offers short courses in the treatment of alcoholism and drug addiction. The psychiatry department also has picked great interest in the area of addiction (researcher’s experience as a part time lecturer at the School of Psychiatric Clinical Officers) Low capacity in the health sector to deal with the problem sighted was as a constraint to some health workers. Health workers have not been specifically oriented to treat alcoholism. Some respondents from the health sector had limited knowledge about the various assessment tools for screening for alcoholism among patients, indicating that the diagnosis could always be missed. An example is from the following quotation: I check the physical appearance such as loss of weight, I have never heard about any screening tests (Medical Staff Mukono Health IV Hospital). Lack of capacity may translate in treating symptoms of alcoholism rather than alcoholism itself. The following quotation points towards this trend: Sometimes, you receive people with injuries in the surgical ward, these people are smelling alcohol, you admit them, while in admission, and they bring in alcohol to drink. When they become a nuisance, the other patients report them to us (Nursing officer Mukono Health Centre IV Hospital). Patients who get admitted for injuries sustained while intoxicated but not referred to the unit could be seen in general wards rather than referred to the alcoholism treatment unit. These patients reportedly continue to use alcohol in the admission wards. Such patients get reported to the nurses when they become a nuisance. The nurses who received special training by MKN were allegedly being removed and given other duties in the hospital, and one had been transferred to another health unit, making the problem of low capacity worse. The inability to address alcoholism as a stand alone condition is based on the fact that in the health surveillance reports, alcoholism as a health condition does not appear although sources from the ministry of health indicate that this data will soon be captured (stakeholders meeting 12th August 2005) To express the need for capacity building in treatment of alcoholism, when asked for comment medical staff made the following request to the researcher: MKN trained a few staff in the district hospital, we should also be given training so that we can run treatment in the lower health units, the facility in MKNdistrict is too far for most people who need help (Mukono Health Centre IV Hospital). 4.3.3 Negative Attitude by Health Workers The attitude towards people with alcoholism is also a challenge. This has been discussed, especially about how individuals were received at the outpatient department. When asked how they treat alcoholics compared to other patients, some health workers said that their initial reaction would be anger towards the patient. The following quotation from a medical worker highlights this challenge. If I receive a patient who is alcoholic, my initial reaction to him is anger though I have to treat him (Nurse Mukono Health Centre IV Hospital). Alcoholics already feel a sense of rejection and hopelessness (Ketcham, 2000) and any attitude that confirms their sense of rejection only serves to demotivate those who would have undergone motivational counseling by MTC field staff. The negative attitude could affect the quality of care for alcoholic patients. Sighting the quality of care given to the patients, a MTC worker noticed that such patients who get rude reception would go back to their villages and give a negative recommendation to others who would be considering coming to the hospital. Usually such patients have friends with the same condition and their successful treatment acts as a motivation to the others. When they do not talk well about the program, others become very hesitant. The following quotation from a MTC field worker confirms the above assertion. When patients with alcoholism go to the hospital and are not treated with kindness, they go back and tell the others that the nurses were rude to them. The ones they tell are their drinking friends who would get discouraged from going to seek treatment (MTC social worker). 4.3.4 Stigma of Alcoholism Stigma presents a challenge to the treatment and prevention program. Although drinking alcohol is culturally accepted, those who lose control over drinking and become a public nuisance are stigmatized. Admitting that one is an alcoholic or has lost control over drinking and therefore needs help becomes a challenge. Being alcoholic carries a level of stigma due to the bio-psychosocial complications associated with the disorder. Stigma attached to being chemically dependent coupled with low capacity (previously discussed above) among the health workers continued to militate against efforts to motivate alcoholics to seek treatment. When MTC made it known that there was a treatment service at the hospital, some patients voluntarily begun going the hospital. According to information, gathered from the mental health department, personnel at the outpatient clinic do not always receive such patients with the courtesy and psychological skills required to handle patients with addiction problems. An example is from the following quotation. These patients are harassed, there was one time in the medical ward, a patient came there and was drunk, and he was chased. They do not treat them well, they send them away saying you go to the mental health clinic (Nurse Mukono Health Centre IV Hospital). Alcoholics have to drink in order to function. In some cases MTC encourages them to take some alcohol before going to hospital to militate against withdrawal symptoms which can be life threatening. The following quotation from a MTC field worker confirms this practice. Sometimes when taking our clients/patients to hospital, some develop tremors and we encourage them to drink a bit of alcohol to stabilize so that they can reach the hospital (MTC social Worker). When patients with alcohol problems reach the hospital and they are “chased” it has implications on the program and also points to the capacity already discussed. Alcoholism as a disease presents its self as a challenge by its very nature and characteristics. As the disease of alcoholism progresses, the alcoholic feels guilt, shame and develops a sort of paranoia towards everybody. Any negative attitude, real or imagined, can only serves to discourage the alcoholic from seeking recovery or, at worst, may increase feelings of worthlessness and hopelessness (Ngabirano, 2000:136). Individuals who regularly commit alcohol-induced crimes are punished instead of being “forced” to seek treatment. This attitude does not help the alcoholic, but increases his/her sense of rejection. Various respondents in positions of authority thought that this is the best option for dealing with alcoholics. This contradicts international guidelines that offer the option for treatment if confirmed that an offender suffers from addictive illness (WHO, 1995, UNODC, 2003, Ketcham and Asbury, 2000). The following quotation from a headmistress summarises this challenge. Teachers are reported to the inspector of schools and district education officer. Teachers are made to retire, for example, recently four teachers were retired, other will learn from their example (Head-teacher). The perceived or real threat of loss of job and rejection serves to sink the patients deeper into denial. The following quotation from the LC V chairman gives an example: In fact we report him to the Chief administrative Officer to be given a warning letter, we also delegate some officers to advise them, the habitual ones are referred to the service commission. For example teachers and police, recently more than ten were sent off. They feel ashamed to go to MTC (Local Council V chairperson). When representatives of stakeholder institutions use penalties for dealing with alcoholism, persons with alcohol problems in these institutions engage in deny and make difficult for MTC to offer the needed assistance. However, MTC was engaging leaders to motivate and support their subordinates with alcohol problems and this was bearing fruit. A few teachers were referred by their heads to MTC and some of them had good recovery rates and were engaged in Alcoholic Anonymous groups (AA) (10 at the time of the research). The following quotation points to this positive aspect. We have trained some community development officers and the Probation Officers in order to begin helping other officers, we also sensitise local council leaders on the need to support their staff with alcohol problems (MTC Area Program Officer). 4.3.5 Lack of Social Support for Recovering Alcoholics The other is the lack of a social support network around those alcoholics who seek to be treated. Individuals with long standing alcoholism tend to lose their family support as the disease progresses, leading to emotional instability, poor judgment, and hostility to family members, friends and the community. When such individuals seek treatment, sometimes the family, friends and the community are not willing to offer emotional and material support necessary for recovering. Lack of family support was sighted for unsuccessful recovery among some patients. The following quotation from an alcoholic summarises this challenge. …I did but did not complete, I do not have support, when I got admitted to the hospital no body can look after me. I was admitted but I escaped, there was no food, I lost my parents, my wife run away from me, left me three children, I get hungry, I ask for alcohol so that I do not feel hunger. There was no body to guard me. I used to be a deputy headmaster. The treatment was okay, but nobody looked at me. If I had assistance I would be normal now. When I was in treatment, I would go and drink. Hunger and thoughts, no family, no property I sold everything (an alcoholic client). When patients go for treatment, they need someone to support them during the times when craving for alcohol is high. They also need to be provided with food since hunger is a trigger for alcohol craving. Due to the fact that they begin to get sober, they begin to think about what they have lost and would need emotional support. During this time feelings of guilt can also be overwhelming. Relapse can occur when there is an absence of the social support network. MTC staff did not seem to be very successfully in engaging families to fully support the patients in treatment. MTC staff therefore engaged in taking full responsibility for the patients and yet they had other tasks to perform. Due to limited resources, there was limited help extended to potential caregivers who would not be able to meet the costs of looking after the patients. About the limited funding, MTC field worker said. We do not have any funds to support patients in treatment and we have to sometimes use our own money to buy food and juices for some very desperate patients (MTCfield Officer). 4.3.6 Program Design In the MTC alcohol program is a visible gap for a rehabilitation component to deal with socio-economic reintegration. Some respondents who had been in the treatment program and relapsed were concerned with lack of skills training as part of the recovery needs. When asked about the recommendations for improvement of the program, one treated individual had this to say Ask government and medical representatives that I would like to be employed; I would like to make myself busy. They should take me back for treatment so that I can be normal like you. We would like to be kept busy. If we can be taken to a safe place for 3 months, we can become better. Right now I have no plan, my duty now is to disturb people. I just want to die now (an alcoholic client). A good treatment program should have a halfway house where individuals in recovery go and begin some sort of employment while at the same time receiving psychosocial support from caregivers. The absence of this facility definitely limits the successful outcomes in treatment goals (Ketcham and Asbury, 2000). Mukono District needs to find alternative ways to the half way house as this seems to be more western and probably not culturally appropriate. However, there is very little doubt that such a modified and culturally adapted arrangement would help some individuals. The challenge here still remains limited resources to address one of the most expensive interventions. The program was also complicated by lack of nutritional rehabilitation for the clients in treatment. Treated individuals and Mukono District staff talked about this limitation. People with alcohol dependency suffer marked vitamin and mineral deficiencies and require nutritional supplements and a balanced diet during treatment in order to realize a better outcome in treatment (Ketcham and Asbury, 2000:207-229). Poor nutrition is linked to relapse and mental confusion during treatment. In a country like Uganda with large numbers of children suffering from malnutrition, sometimes a choice has to be made between a child and an adult in considering whom to give nutritional rehabilitation to and this was clear to me during the research. This quotation summarises the challenge. We have a limited supply of vitamin A tablets and we can only give to children and not adults (Nurse Moyo). Nevertheless, lack of this component in treatment limits the treatment outcome in the MTC program. 4.3.7 Access to Detoxification Services The location of the Detoxification Unit was also seen as prohibitive in terms of accessibility. Some Mukono District counselors and health workers in the subcounty health units thought that this was a barrier. Individuals who would like to go for treatment find the distance very long and cannot afford the transport costs involved and were instead requesting the detoxification services to be availed at the lower level health units. The following quotation from a health worker confirms this setback. When we get some patients, we refer them to Mukono Health Centre IV Hospital but they do not go sighting transport problems. If government was to come in, the staff at lower units could be given special training to treat alcoholism. This would make the service more accessible and affordable. 4.3.8 Lack of Essential Drugs for the Treatment of Alcoholism The health workers and Mukono District counselors lamented lack of certain essential medication and a total lack of certain specialized drugs in the treatment of alcoholism. Drugs, such as Librium, which is a basic drug for detoxification, would sometimes be lacking or in short supply. Specialised drugs such as Antabuse, are conspicuously absent from the essential drugs list. Evidence available showed that this drug has ever been used in the history of Uganda but somehow disappeared for reasons that are not available in literature (Principal medical Officer-In charge of mental health). This drug, in my view, would be useful for certain individuals and available evidence also shows that traditional healers, to treat addiction, crudely use aversion therapy (one such healer was visited by the researcher in Arua town). The shortage of drugs could be linked to the little emphasis put on alcoholism as a public health problem. 4.3.9 Late Diagnosis Due to lack of policy on alcohol in the Ministry of Health strategic plan, individuals with alcohol problems are not diagnosed early enough. This implies that middle or late stage alcoholics abound in the Mukono District program. Individuals who come for treatment usually have marked mental and psychological complications, sometimes with marked impaired judgment. Treating such individuals needs a lot of resources and sometimes the outcome is not usually quite predictable. In limited resource settings in which the MTC program works, it becomes very difficult to help such individuals. The following quotation from a MTC field staff points to this complication. Sometimes people come when they are very sick, one time one almost lost his life while in treatment, this could have caused a lot of problems in the community because this man left home when he was walking by himself, sometimes when you try to help some, their sense of judgment is so poor that they ask you to buy for them alcohol (MTC field officer). Various respondents pointed out lack of government commitment to fighting the problem of alcoholism. This was partly epitomized in the desperate attempts by various communities to try and put controls without a supportive or matching government policy on alcohol and substance abuse. When asked how the communities were controlling the abuse of alcohol some respondents sighted self-initiated community bylaws in a desperate attempt to address alcoholism. The byelaws varied from village to village and therefore not even uniform at the district level. Responses showed that these bylaws are a desperate attempt to control one of the sighted most serious problems facing the population. To point the desperate attempts to control alcohol related problems by the community, a local council III official said: We have byelaws and regulations set up by the community at village level, but they are not executed. The government gave up with a law set in the 1960’s (Local Council III official). 4.3.10 Insufficient Funds Little donor interest in alcohol programming has had an effect on the problem. Alcohol abuse, though sighted in several needs-assessment reports and researches (done in Uganda) has not received matching programming commitment. The MTC alcohol program in Mayo only operated on a budget of 10000 US dollars for a period of one year and a half. This money was only enough to carry out community education. The program severely lacked other essential elements of good practice in alcohol programming, such as social rehabilitation of treated individuals and frequent home follow up support to recovering individuals. Records available regarding treated individuals indicated that individuals who were employed by government or were self-employed (10 teachers and one carpenter) with a specific life skill tended to do better than those without any form of survival skill. MTC did not have a component of skills training essential for a holistic treatment package. MTC staff also reported extreme distress on their part resulting from using personal resources to support the nutritional and sometimes medical needs of some clients who lacked the necessary social support network around them. The following quotation from a MTC counselor sums up the above problem of lack of funds for the program. One client from Dufile who came willingly to the detoxification unit and did not have any family support almost lost his life in the process of treatment He did not have proper food. I had to purchase fruits, juices to support his recovery…This means that treating clients of that nature then you are overwhelmed (MTC Field Officer). 4.3.11 Political Interference and Alcoholism Politicisation of alcohol was a major challenge in alcohol programming. Some politicians were allegedly frustrating the work of the police in stopping the importation of crude distillates from Kasese and Lira districts. The allegations are contained in the following quotation from a police officer based in Mukono The law is not in force currently, those days it used to work; it should be revised to give us strength to deal with the consumers and manufacturers. You cannot now arrest anybody and especially the community believes that alcohol is their survival, you do ABC the politicians come in (Police Officer). Politicians are also allegedly using alcohol to buy their way to political positions. It is alleged that unless one “wets” the throat of the voters, one cannot be possibly elected. A local council official during the interview said: When you are campaigning, the people touch their throats indicating that you have to wet their throats with alcohol in exchange for votes, one local council official was removed by the community for allegedly taking a tough stance on alcohol (Local Council V official). The community allegedly uses blackmail to stop politicians at the lower level from enforcing any alcohol legislation. An interview with a Local Council Official revealed that one official was removed from office for being very strict on alcohol consumption. Political inaction on alcohol has also been noted at the national level by various concerned individuals (Ngabirano, 2003). 4.3.12 Community Attitude towards Drinking Not withstanding the fact that the community has spoken out about the effects of alcohol on their welfare (UPPAR, 2000), deep misconceptions about what alcohol actually is remain. Alcohol use is perceived as central to the community life and all occasions have alcohol as part of the celebration. Some community members also still think that alcohol is food. There is an inherent contradiction in the community. The community perceives alcohol as causing a lot of problems and yet the attitude towards drinking is favourable to increasing the number of people with alcohol problems. About Community attitude towards drinking, WHO, (1994) warns that the drinker’s risk of becoming a heavy or problematic drinker depends on the “wetness” of drinking culture to which they belong. A person in a fairer “dry” environment would be a lighter or moderate drinker but may be a heavy drinker where alcohol is cheap, easy to obtain and is a routine part of life. The following quotation from the probation and social welfare officer highlights this dilemma When someone commits alcohol induced offences, he/she is given a fine of paying alcohol in kind and actually participates in the drinking as well. When a child is born, alcohol is put on the tongue as a sign of initiation to alcohol (Probation and Social Welfare Officer). 4.3.13 Gender Extreme poverty among women (feminization of poverty) continues to be a challenge, especially, in regard to reducing the amount alcohol produced within households. Alcohol distillation and brewing is a “major” income generating activity among women. Politicians tend to sight this as a reason for inaction. To emphasize his point of view, a local council leader said: My mother used to brew alcohol to pay for my school fees; it is a major income generation activity for the women in the homes (Local Council V official). Another local leader said: The challenge is the poverty. People here find that brewing and distilling alcohol is the source of income. There are no other cash crops; people think that alcohol is the only source of income (Local Council III chairperson). One woman brewer also pointed out this fact although there was a tone of despair in the conclusion of the sentence to point out the fact that is a desperate move to survive. It is a major source of income for me because I use it to support the family for food, medicine, clothing, and other necessities. My husband cares less about the children; he drinks all the money he gets. I have to brew in order to survive (a woman brewer). However, some women brewers had a different view of alcohol production as a source of income. Some admitted brewing and distilling had fewer returns compared to the amount of effort involved while others blamed the practice of distillation to ill health of women distillers and revealed that if there were alternative sources of income they would stop. The research through joint assessment with the brewers established that most made a profit of 500-1000 Uganda shillings and this excluded the cost of fire wood and water as these are got from nature for free. The work involved in distilling takes a period of 2 weeks and one full day of distillation (from 6am to 6pm) to produce less than 15 litres of the crude distillate. The link between home distillation and environmental degradation due to deforestation for firewood has not been studied. Women have to travel long distances in search of firewood. The dangers of this such as rape and snake bites have been extensively studied (UNHCR, 2003) The following quotations from women brewers clarify the poverty link and allegations of ill health resulting from heavy work and exposure to smoke in the process of distillation My chest sounds like an empty barrel because of exposure to smoke, it is a health hazard to distill, if I had an alternative I would stop brewing given the risks and little returns realized (a woman alcohol brewer). The debate on whether poverty leads to brewing alcohol or whether alcohol brewing in the community worsens poverty remains inconclusive. The above quotations bring about several issues. The consumption of alcohol especially among men leads to obligating family responsibilities and forces women to take on the burden of single handedly taking care of the family. The availability of alcohol in homes promotes early initiation to alcohol use among children. The perception that brewing alcohol is the only source of income may also militate against community innovativeness and response to new suggestions on income generation as alcohol brewing brings about “immediate returns”. The Uganda Participatory Poverty assessment Process also revealed that women blamed household poverty on drinking among men who in the process become socially and economically dysfunctional (UPPAR, 2000). 4.4 Opportunities for Treatment and Prevention of Alcoholism This section presents an overview of the opportunities revealed by the research in alcohol programming. Although major challenges emerged from the research findings, alcohol programming in Uganda may provide certain opportunities. From the responses, people seem to be more likely to accept alcoholism when it is considered a disease rather than as a habit or a moral weakness and an attempt to run a way from reality. 4.4.1 Presence of Treated Individuals in the Community When individuals, perceived by the community as a nuisance and hopeless, recover, the community becomes more favourable to the program and seems more likely to accept and support the program. The following quotation brings out a positive aspect of alcohol programming. I have seen two individuals recover, for those who have been helped to come to their senses and some have been reemployed after loss of job and this has motivated many to seek treatment (Local Council V chairperson). From this quotation, a conclusion can be drawn that if resources are put into treating affected individuals, the community is likely to appreciate the problems associated with alcohol and offer support to the program. 4.4.2 Availability of Specially Trained Health Workers The Mukono District program indicated that when health workers are given special training on addiction, they tend to be more compassionate towards individuals with alcohol or drug problems. This was clear during the interview. Health workers who had received training from MTC demonstrated commitment and patience towards alcoholic patients. For example one trained nurse had this to say about other staff that did not receive training They do not give them health education; they send them to me saying “go to the mental health clinic¬ (Nurse in charge of the detoxification Unit). 4.4.3 The Presence of Interested Stakeholders in the Community. Alcohol education and sensitization in the community make it easier for politicians to talk about alcohol problems in the community. Community leaders who held political positions expressed that it was difficult for them to discuss alcohol in the community, but with the work of MKN, they were now able to talk about it and to motivate their communities to set up bylaws. The quotation below from a local council leader points out this opportunity. With help of MTC, I can now freely discuss alcohol problems with the community, this was very difficult before (Local Council V chairperson). This quotation reaffirms the opportunities embedded in expression of joint concern by political and non political actors in the fight against alcohol abuse. Community education helps communities to take action. Responses from MTC staff, women brewers, community leaders and alcoholic patients revealed that the education they had received from Mukono District staff helped them to refer patients to seek treatment. When communities were asked to set up bylaws and to discuss the problem in their community meetings, the response, according to the politicians and other community leaders, was good although challenges of implementation abound. One local leader had this to say; We have been carrying out sensitization, setting up time limits by setting bye-laws, we encourage people to go to the gardens and come back by 2:00pm, so this is the time we have set keeping the community busy all the time by organizing seminars and so on (Local Council II chairperson). This quotation brings about opportunities presented by training local leaders in basic alcohol issues. When the capacity in the local leadership is raised, the number of actors in alcohol programming is raised. On community action following MTC program, one religious leader had this to say. After prayers, I tell them the dangers of alcohol. I went to the local council one leader to put bye-laws in order to control alcohol in our area. We also had a meeting to bar promotion of alcohol in our area. I have also been going to those with alcoholism to give individual and family counseling (Church leader). This quotation presents an opportunity in working more closely with religious leaders especially religions that do not have a more fundamentalist view of alcohol such as the Catholic Church. A more positive disposition towards alcohol is more likely to meet community favour due the fact that alcohol is and will continue to be part of social life. 4.4.4 Community Demand for Action From the responses, it is clear that the community wants government to take action against alcohol. Although the recommendations varied as shall be outlined later, community awareness is more likely to result in pressure on government to put in place mechanisms to address the problem of alcohol abuse. An example is from the following quotation: The government should be fully involved with other NGOs who are interested in carrying out these activities because alcohol is not only an individual but national issue, the government should put resources to create awareness and to treat this kind of people (Church leader). This quotation indicates that when community capacity is built through sensitization and education, they are likely to demand for services and action from government. The gap that currently exists between government and other actors in alcohol programming can be closed when the community puts pressure on government to act. However, concurrent programs of poverty alleviation have to be put in place most especially alternative income generation activities at household level. CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS 5.0 Conclusions The community and community leaders have commended the MTC alcohol program as a welcome intervention. The MTC alcohol program included community education, training of Non-Governmental Organizations, and referral of Alcoholic patients, psychosocial counseling and production of education materials. Research findings revealed major challenges as well as opportunities in the alcohol programming, based on the success recorded. These can be put under three broad categories and these are community challenges and opportunities, institutional challenges and opportunities and individual challenges and opportunities. The community challenge is the attitude towards alcohol that seems to be intertwined with a culture that encourages alcohol abuse. The other major challenge is the widespread lack of opportunities for the community to raise income. Poverty among women seems to be one of the major challenges. Although the community supports the program, pointed out lack of opportunities especially for women as a major setback in addressing alcohol availability. As a result, alcohol is available and easily accessible. Despite this major challenge, the community also presented opportunities. These included the benefits of alcohol education and community sensitization and treatment. Examples of successfully treated individuals yielded some measure of community acceptance of the program. This was evidenced by the presence of byelaws in most communities as well as the referral system for treatment. Institutional challenges included lack of government policy on alcohol and substance abuse in general. Lack of specially trained medical staff in prevention and treatment of chemical dependency also presented a major setback to the program. Lack of resources within the health units epitomized by periodic shortages of essential drugs in the hospital also continued to impact negatively on treatment. Lack of resources could not enable the hospital to assign full time staff to the detoxification, provide community education and provide nutritional therapy required in the treatment and rehabilitation process of chemical dependency. Political interference and political blackmail by the community were also mentioned as a major institutional challenge. However, there were also major opportunities presented, for example, willingness of staff to be trained, the availability of hospital space for treatment, procurement of drugs by the district, despite the limited supply, encouraging the communities to set up bylaws and availing district staff to participate in alcohol programming. Individual challenges included long-standing disease progression, lack of employment opportunities for some clients and lack of a family support system for recovering individuals. The opportunities presented at the individual level, were, the examples in the communities of treated individuals who remained sober over a period of time. Mukono’s interventions despite the challenges were registering an important contribution to community health and development. 5.1 Recommendations The study draws some recommendations to the various categories of stakeholders. The recommendations are for MTC, the community, the local government, the health workers and to those interested in carrying out further studies in the area of alcohol. 5.1.1Recommendations to MTC • Continue advocating for an alcohol and substance abuse policy. • Integrate skills training for socio-economic reintegration of the people they treat. • Continue to work with the medical professionals to find a common working definition of alcoholism. • Continue advocating for increased funding for alcohol programming. • Work closely with existing community structures to mobilize the community to support individuals and families with persons with alcohol problems. 5.1.2 Recommendations to Community • To put in place and adhere to contextually appropriate alcohol byelaws for self protection. • Organize themselves to support members with alcohol problems. This could be done by utilizing the traditional leadership structures as well as the local council leadership systems. 5.1.3 Recommendations to Local Government • Working with the central government to draw an alcohol policy. • Identification of alternative income generating activities for especially women. • To look for mechanisms of reducing or controlling home based distillations. • To continue carrying out community dialogue and sensitization about the dangers of alcohol abuse. • Look for ways of supporting community members with alcohol problems to access and stay in treatment. 5.1.4 Recommendations to Central Government • Develop an alcohol policy. • The ministry of health to provide specialized training in treatment of substance abuse. • Provision of specialized drugs for treatment of addiction. • Set up detoxification services at lower health centres. • Provide resources to target alcohol education in communities. 5.2 Areas for Further Investigation As a recommendation, social economic studies should be conducted to further understand the argument put forward by communities and government that alcohol production and consumption is a major source of income. The Studies could focus on: 5.2.1 The Family The spouse and children in terms of psychological and physical trauma as well as educational, social and financial hardships related to alcohol abuse. These studies could be done a team of mental health experts, social scientists and economic analysts. 5.2.2 The Public Victims of drunk driving, violent crimes, or workmates affected by an alcohol related industrial accident. These studies could be carried by insurance companies, the Ministry of Internal Affairs police, the ministry of Gender, Labour and Social Development. 5.2.3 The Society Costs in lost production, food security, welfare, health services, insurance, law enforcement, the courts, and the environmental impact in terms of pollution, and deforestation. The Ministry of Finance and Economic Planning should take a lead in these studies. Similar studies else where have placed a case for action (Alcohol Policy and the Public Good, WHO, 1995, Geneva). 5.2.4 The relationship between HIV, STDs and Alcohol A study could be conducted to establish a relationship between alcohol abuse and the spread of HIV and STDs. The Ministry of Health and Schools of public Health could lead in this process.   REFERENCES Books Al-Anon Family Groups, (1981). Al.Anonp’s Twelve Steps and Twelve Traditions. Virginia Beach: Al-Anon Family Group Headquarters, Inc. Alcoholics Anonymous, (1997). New York: Alcoholics Anonymous World Services Inc. Baron, N. and Soren, J., (2001). Guidelines for treatment of alcoholism. Kampala:TPO Bradshaw, J., (1990). Home Coming: Reclaiming and Championing your Inner Child. Auckland: Bantam Books. Bradshaw, J., (1988). Healing the Shame that Binds You. Deerfield Beach: Health Communications, Inc. Castelli, J. and King, E., (1995). Culture of Recovery, Culture of Denial: Alcoholism among Men and Women Religious. Washington: CARA. Indiana University-Centre for Adolescence: Building an Effective Alcohol Prevention Program; Teacher Talk 3 (3). Jarema, W.J., (1994). Fathering the Next Generation: Men Mentoring Men. New York: Crossroad. Jellinek, E.M., (1960). The Concept of Alcoholism. NJ: Hill House Press. Kaplan, H. I. and Sadock, B., (1987). Synopsis of Psychiatry: Behavioural Sciences Clinical Psychiatry: Washington: American Psychiatric Association. Ketcham, K. and Asbury, F. W., (2000) Beyond the Influence:Understanding and Defeating Alcoholism. New York: Bentam Books. Kigozi & Kasirye ,(1997). Alcohol, Drug Abuse and HIV AIDS in Uganda: A consultancy for Uganda AIDS Commission, Kampala. Ketcham, K. and Asbury, W., (2000). Beyond the Influence: Understanding and Defeating Alcoholism. Toronto: Bantam Books. Ketcham, K. and Milam, J., (1988). Under the Influence: A Guide to the Myths and Realities of Alcoholism. Auckland: Bantam Books. Martin, J.C., (1982). Chalk Talks on Alcohol. New York: HarperCollins Publishers. Mbona, T.N. and Kasirye, R., (Nov. 2003) Gender, Alcohol and Culture International Study (GENACIS) in Uganda: Uganda Country Report. Submitted to WHO, Geneva. Milam and Ketcham, (1988) Under the Influence: A guide to the Myths and Realities of Alcoholims. New York: Bentam Books. Miller, M. and Gorski, T., (1986). Staying Sober: A Guide for Relapse Prevention. Missouri: Herald House. Ministry of Health, Republic of Uganda ,(2000). Health Sector Strategic Plan 2000/01/05. Kampala (unpublished). Ngabirano. E., (in New Vision 21/7/2003) Government should control Alcohol. Kampala: New Vision. Ngabirano, E., (in Monitor 26/7/2003). Do something about Alcohol. Kampala: Monitor publications. The Uganda AIDS Commission, Republic of Uganda (2001). Strategic Plan 2001-2005. Kampala. New Vision The World Health Organisation Report, (2001). Mental Health: The New Understanding. New Hope. Geneva. Transcultural Psychosocial Organisation., (2001). Alcohol and Other Drugs. Jaffna: TPO. TPO Activity Report, 2002. TPO: Kampala. Uganda Participatory Poverty Assessment Report, (2000). Learning from the Poor. Kampala: Ministry of Finance, Planning and Economic Development. United Nations Office on Drugs and Crime, (2003). Drug abuse Treatment and Rehabilitation: A Practical Planning and Implementation Guide. United Nations: New York. United Nations Office on Drugs and Crime and World Health Organisation., (2004). A strong Start: Good Practices in using a local situation assessment to begin a youth substance abuse prevention project. Vienna: UNODC United Nations High Commission For Refugees ,(2003). Sexual and Gender-Based Violence against Refugees, Returnees and Internally Displaced Persons. Geneva:UNHCR. Vannicelli, M., (2002). A Dualistic Model for Group Treatment of Alcohol Problem; Abstinence based Treatment. Harvard International Journal of Group Psychotherapy 52 (2); Department of Psychiatry. Wilcocks, L., (1992). Alcohol Abuse: How to Help Someone You Love. Pinegorie: Aspen-Oak Associates. WHO., (1995). A summary of Alcohol Policy and The Public Good. Brussels: EUROCARE and Oxford University Press. Woittitz, J, G., (1983). Adult Children of Alcoholics. Deerfield Beach: Health Communications, Inc. Websites AlcoholAlert, National Institute on Alcohol Abuse and Alcoholism No. 30—PH 359 – October 1995, available at: URL: http://www.drugs.indiana.edu/publications/ncadi/alerts/htm/alert 30.html. Accessed on 22/06/2003. APHRU (30th June 2002). “Submission to the ASA Review on Alcohol Advertising”, available at: URL: http://www.aphru.ac.nz/hot/adsub.htm. accessed on 20/06/2003. Encarta Encyclopedia, “Alcoholism”, available at: URL:http://encarta.msn.com/encnet/refpages/RefArticle.aspx?refid=761552168&pn=2&s=11. accessed on 10/6/2003. Healthier You, (2004), Facts about alcoholism, available at: http//www.healthieryou.com/alco.html Helzeldon ,(2000). Available at www.Helzeldon.org Gapa (Global Alcohol Policy Alliance), A Conference held in Syracuse, New York, in the summer of 2000, available at: URL: http://www.isa.org.uk/theglobe/2001gapa1/gapa.htm. accessed on 20/06/2003. Grant BF., (2000). “Estimates of US Children Exposed to Alcohol Abuse and Dependence in the Family”. American Journal of Public Health 90(1):112-115, available at: URL: http://www.aloholfreechildren.org/gs/pubs/html/Stat.htm. accessed on 04/06/2003 Health Canada , (2003). Available at: http://www.google.com/search?hl=en&p=Health+Canada+on+abuse+and +a…09/09/2004 National Institute on Alcohol Abuse and Alcoholism (March 21,1997). “Combined Behavioral/Pharmacologic Treatment of Alcoholism” available at: URL: http:www.apa.org/science/niaaa.html. accessed on 22/06/2003. National Council on Alcohol abuse and Alcoholism (09/08/2002) available at http://scholar .google.com/scholar?p=National+Council+on+alcohol+abuse+and+alco…..09/08/2002 WHO (2004) Reducing Harm from use of Alcohol-community Response. Available at:http://64.233.183.104/search?p=cache:ix9H0pXW0pEJ:www.aearo.who.int/LinkFiles…09/09/2004 Willis, J. (2007) “Clean Spirit”: Distilling, Modernity and the Uganda State, 1950-86’, Journal of Eastern African Studies. Available at; Http://www.informaworld.com/smpp/tittle ¬content=t770239509. Online publication 01 March 2007 (www.youthaiduganda .org 7th May 2002 APPENDICES Appendix 1: Interview Guide Dear Respondent, My Name is Kikonyogo Robert, I am a BGC student from Kyambogo University. Thank you for allowing me to use some of your time for this interview. The intention of this interview is to get your views on the causes of alcoholism among the youth. The responses you give shall not in any way be identified with your name. Your responses are highly valued as they will contribute towards the causes of alcoholism among the youth in Mukono Town Council;. I once again thank you very much for agreeing to be interviewed. SECTION A: FOR MEDICAL WORKERS 1. Please explain why you would consider or not consider alcoholism primary a diseases. 2. What activities have you been carrying out in the hospital and in the community regarding alcoholism 3. What tools do you use for screening for alcoholism? (probe whether they usually probe for alcoholism among patients who otherwise come with other complaints for example malaria) 4. Have you had training in diagnosis and treatment of alcoholism and related disorders? (probe where this was done and if not the reasons for lack of this training) 5. When you have ascertained that a patient has an alcohol problem, what do you usually do? (probe for counseling and explanation of the condition to the patient) 6. When you have admitted a patient for alcoholism what is the typical treatment procedure (probe for medical counseling sessions, frequency per person and length of sessions). 7. What drugs do you use for treatment and prevention of alcoholism? (probe for availability of anti-abuse and essential drugs and drugs used in detoxification, also ask why they are not available if the respondent says so) 8. How is an alcoholic patient compared to other patients treated during admission? (probe for a special unit that has specifications for detoxification) 9. How are the nutritional requirements for alcoholic patients met at the hospital (probe for the component of nutritional rehabilitation and whether the alcoholic patients are considered eligible for nutrition supplements) 10. Any questions or comments Thank you. SECTION B: FOR MUKONO DISTRICT STAFF 1. Does Mukono consider alcoholism as a primary disease/ please explain the answer you have just given. 2. How do you usually get clients with alcohol problems? 3. What challenges do you face in motivating alcoholic clients to go for treatment? 4. What would you say about the community in as far as support of the program is concerned? (probe for community cooperation and challenges) 5. In treatment of alcoholism what problems do you face? 6. What sought of collaboration do you get from other community structures such as churches, police, local government, health units etc? 7. What challenges do you face in collaborating with other sectors? 8. Do you have support groups for alcoholic clients? If yes what challenges do you face in forming and maintaining these groups? 9. From your experience how are the policies and laws governing alcohol use working in the community? 10. How does the community regulate access to alcohol for young people? 11. How does the community access alcohol and how easy is this access? 12. How does the community support your treatment and prevention program? 13. How does the community react to the suggestion of reducing and controlling production of alcohol? 14. How is alcohol education contributing to the program/ who carries out this education? 15. How do schools carry out alcohol education? 16. How do schools controls use of alcohol among students? 17. When individuals commit alcohol abuse related crimes how are they normally treated? 18. Briefly explain to me the process you take in the treatment of alcoholism. 19. What good things or success you see in treatment and prevention of alcoholism? 20. Any other comments or have you got a question? SECTION C: FOR COMMUNITY LEADERS AND LAW ENFORCEMENT OFFICERS 1. Do you consider alcoholism as a disease? Would please explain the answer you have just given? 2. What is your opinion on controlling production, distribution and consumption of alcohol in the community? 3. As leaders, how have you been controlling production, distribution and consumption of alcohol in the community? 4. Do you have any guidelines on alcohol in the community? How has the community cooperated with the guidelines? 5. How do you treat someone who regularly commits alcohol abuse induced crimes? 6. How do you treat officials with alcohol problems? What impact does this have on prevention and treatment of alcoholism among officials and the community? 7. What are the major challenges faced in prevention of alcohol abuse? 8. How does leadership support alcohol abuse prevention and treatment program in the community? (probe for budget allocation) 9. What measures have you put in place to prevent alcohol abuse? 10. How have you been personally involved in treatment and prevention of alcoholism? 11. What are the major issues discussed about alcohol in your official meetings? SECTION D: FOR ALCOHOLIC CLIENTS 1. What have you been told about continued use of alcohol? 2. Have you been told about treatment for alcoholism? What have you done about this message? Would you please explain the reasons for your action or decision? 3. Have you received treatment for alcoholism? What process do did you go through? 4. What were the major problems faced during treatment both in the hospital and in the community? 5. What was good during treatment? 6. How was the family/employer supporting you in the treatment? 7. What were the community leaders telling you about alcohol abuse? What actions did they take or have taken? 8. What has motivated you to stay sober and what has not motivated to stay sober? 9. If you were asked to give recommendations regarding treatment and prevention of alcohol abuse what would you say? 10. Why do you think there is a problem of alcohol abuse in your community? 11. What would be your comment if someone said that alcoholism is a disease? 12. Any other comment or question? Thank you. SECTION E: FOR WOMEN ALCOHOL BREWERS 1. How can you contribute to the reduction of alcohol abuse in your community? 2. How have you personally reacted to the messages in MTC’s alcohol education? 3. How have you been involved in motivating some of your clients with alcohol problems to seek help? 4. What do the community leaders say about the availability and distillation of alcohol in the households? 5. How have you been supporting clients who have gone for treatment at the hospital and by MTC staff? 6. Why do you think community leaders have not stopped production of alcohol in the households? 7. How would you react if community leaders stopped you from producing alcohol? What reasons would you give for the reaction? 8. Any question or comment? Thank you.