Treatment for Women with Substance Use Disorders: The Internet Can be a Facilitator or A Barrier to Care in the Caribbean

Access to care is characterized as the opportunity to reach and obtain appropriate healthcare services to satisfy a perceived need [1]. In 2021 an estimated 39.5 million people worldwide were reported to have Substance Use Disorders (SUDs), but fewer than 1 in 5 people received SUD treatment [2]. One theme of the worldwide data is that women are underrepresented in treatment compared to men. For example, almost 1 in 2 people who use amphetamine-type substances is a woman, but only 1 in 4 people who receive treatment are women [2]. As women face significantly more barriers than men when seeking SUD care, the authors call for the identification of pre-existing fast and simple solutions to improve access to accurate information about SUD treatment as a first step to accessing care. 

More than 20 years ago the Pan American Health Organization articulated the following priorities for Latin America and the Caribbean: the development of national policies and a regulatory framework for information technology; addressing inequity of digital access; and assisting countries in becoming skilled at taking full advantage of new technologies and reaching appropriate decisions regarding the selection and deployment of alternative information technologies [3]. It is estimated that 76% of the population in Latin America and the Caribbean uses the Internet [4]. Thus, a large proportion of this population can access information about different services, if it is available online. 

A summary of reviews which explored the barriers and facilitators to SUD treatment identified barriers as limited treatment slots for patients, inconsistent funding sources and stigma experienced by minoritized patients. Strengths identified in the treatment programs included accessibility of treatment resources, flexibility and competence in the delivery of services, and cultural relevance of services [5]. Mothers with SUDs face more structural barriers than other patients seeking treatment. Specific barriers typically encountered include unavailability of treatment resources, conflict between treatment programming and the mother’s role, and the absence of treatment planning for expectant mothers [6]. 

An analysis of 28 qualitative studies reported obstacles to accessing treatment that included shame and stigma associated with substance misuse, the difficulty of getting assistance, the limited availability and variety of programs, the high expense of therapies and medications, and worries around confidentiality [7]. As stated, the research clearly indicates that easy, quick, and confidential access to information about treatment for SUDs is an urgent necessity for women living with these disorders. 

In the Caribbean basin the main substances used in the last 30 days by persons referred for SUD treatment assessment were: alcohol 62% (2,797), marijuana 55% (2,474), tobacco 43% (1,936), crack cocaine 31% (1,383), and cocaine powder 8% (365). Both males and females reported the same rank-order pattern of use [8]. While substance use affects both men and women, women represent just 10% of individuals seeking SUD treatment in this part of the world [8]. While systematic data on treatment access and entry, disaggregated by sex and gender, are lacking for every country in the Caribbean, an important study of female commercial sex workers in Guyana found that 88% (119) of respondents reported regular alcohol consumption while looking for clients; 22% (27) said they smoked cocaine; and 42% (51) reported use of cannabis [9]. 

Barriers which impede women from accessing treatment for SUDs are numerous, and include family responsibilities, relational factors including gender-based violence, mental health challenges, and ambivalence regarding abstinence [10,11]. Higher levels of perceived stigma for women compared to men with SUDs is another overarching barrier to treatment across cultures [12]. Women who use substances often face double stigmatization. First, for the substance use itself. Second, for not fulfilling normative gender and family roles [13]. 

In Trinidad and Tobago, a study determined the critical incidents that contribute to the initiation of substance use. Twenty women attending rehabilitation centers were selected at random and interviewed. Intrinsic factors identified for initiation of substance use included low self-esteem, introversion, loneliness, using substances as a coping mechanism and medical issues. Extrinsic factors for initiation of use included family, social, and environmental factors, relationship issues, child abuse, peer pressure and lack of access to women-oriented treatment programs. Furthermore, the study found that women with substance use disorders commonly experienced being labeled as promiscuous and immoral. These factors are believed to decrease the probability that women will seek and access treatment [14]. 

A basic first step in reducing barriers for women to access SUD treatment is to ensure they have information about available treatment services. Because most potential patients seek information about treatment online [15], digital visibility of available resources could provide women with a private, low-cost, secure way to find the right support [16]. The purpose of the present study was to explore the question of whether the SUD treatment programs reported in the Directory could be located with a simple internet search. If they could be located, then to what extent was information about treatment services provided.

For the present paper, the countries listed in the Directory were included. These 14 countries are Antigua and Barbuda, Bahamas, Barbados, Belize, Grenada, Guyana, Haiti, Jamaica, Dominica, Saint Kitts and Nevis, Saint Vincent and the Grenadines, St. Lucia, Suriname, and Trinidad and Tobago [8] (Table 1, Panel A). 

Table 1: The percentage of the population in the Caribbean using the internet, treatment centers with an online presence and recommendations for improving digital information for substance use disorder treatment centers. 

The digital search was conducted between April 30, 2023, and June 15, 2023, using Google Chrome, Facebook, and Instagram in Rosario, Argentina. In Google Chrome the keywords used were the name of each country plus the name of the institution listed in the Directory. The online searches also included the name of each country plus keywords such as ‘drug use treatment center,’ ‘drug treatment,’ and ‘treatment for drug use.’ On Facebook, the name of each institution listed in the Directory was searched for in the general search bar. Facebook Marketplace was also searched for the name of the country plus ‘drug treatment center.’ On Instagram, the keywords used were the name of each country plus the name of the institution stated in the Directory. This study did not include human subjects and is exempt from ethics approval. This research was conducted entirely through internet searches and desk reviews of relevant documents. 

The outcomes of interest examined in this study were: (1) digital presence which was defined as evidence of any information about the center online; (2) minimal digital footprint which was defined as evidence stating only the name of the center and the city where it is located and 3) people using the Internet (% of the population), which was determined by data retrieved from the International Telecommunications Union [4].

As seen in Table 1, Panel A, there are 14 Caribbean countries with 82 SUD treatment programs. Internet usage in these countries ranges from 96% to 39%, with an average internet penetration rate in these countries of 78%. The total number of SUD treatment centers with a digital presence was 37. 

The search included a total of 82 treatment programs from 14 countries offering treatment services as reported in the Directory. Our findings revealed that 55% (45) of the treatment centers have no digital presence, and that the remaining 45% (37) have a minimal digital footprint, stating only the name of the center and the city where it is located. Of these 37 programs with a minimal digital footprint, none had an internet presence specific to their work but were instead represented either by the official webpages of larger institutions with which they are affiliated or by Facebook pages. These webpages do not mention substance use disorders or treatment resources. Thus, none of the 37 programs provided any information about services offered, the population treated, the type of treatment, costs, length of stay, availability of childcare services, or the admission process. In sum, the 82 programs surveyed have an overall lack of information available on-line to allow a potential patient to find treatment resources and make a judgment about seeking admission. 

This limited digital presence for SUD treatment programs across the Caribbean region stands in stark contrast to the average estimated internet use in this part of the world, which is 76% of the population [4]. To support the availability of treatment information, the authors have created a proposed template that program leaders can use in posting about their programs’ services on the Internet (Table 1, Panel B).

The Caribbean region mirrors most other parts of the world in the scarcity of SUD treatment services. This relative lack of SUD treatment resources is compounded by the absence of a meaningful digital footprint for the majority of programs surveyed in this study. Considering that women already experience significantly more barriers than men when seeking SUD treatment, any improvement in the digital visibility of SUD treatment programs could significantly augment women’s access to treatment. Harmful substance use has significant implications for the person themselves, their family, friends, work colleagues and the wider community. The fact that prospective patients in the Caribbean cannot reliably locate online information about SUD treatment represents a low-cost, low-investment opportunity for substantial public health improvement. 

We urge SUD treatment providers in the Caribbean to take advantage of the near-ubiquitous presence of the Internet to advertise their services. If essential information about treatment resources can be found via a simple internet search, more people, including women, with SUDs will be able to consider taking steps to access appropriate care. This in turn may lead to a reduction in morbidity and mortality associated with SUDs in the Caribbean basin. 

A limitation of this study is the fact that this was a desktop search and other treatment programs or information may be available beyond the scope of this review. 

Future studies should examine the ways women in the Caribbean seek treatment for SUD and how they acquire information about treatment programs. Studies could also systematically test different formats for treatment information to see which are most useful to the potential patient.

We thank OAS-CICAD for their review of the manuscript.

This work was supported by the National Institute on Drug Abuse [R01DA042822], the Bureau of International Narcotic and Law Enforcement Affairs (INL), the U.S. Department of State and The Colombo Plan Secretariat.

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