Challenges Faced by Parents of youth Abusing Substances in Selected Hospitals in Limpopo Province, South Africa

: Background: Once the youth is abusing substances or is diagnosed with a substance abuse disorder, the parents have to rearrange their lives. They do their best to adjust to the new normal of taking care of a substance abuser in the house. Some parents manage taking care of their youth abusing substances well, while others fail because of the challenges they face taking care of their youth abusing substances. This process has become a significant burden whereby the parents need assistance. Methods: A qualitative, explorative, descriptive, contextual design was used to explore the challenges faced by parents of youth abusing substances. Non-probability, homogeneous purposive sampling was used in selecting the study participants. Data was collected through semi-structured interviews with a guide. Data saturation was reached at the 14 th participant. Tech’s method of data analysis was used for the analysis of data. Results: The study’s findings have revealed that parents of youth abusing substances go through challenges such as lack of support from nurses, lack of support from other family members, lack of support from other health care workers. They are also faced with challenges such as youth not adhering to medical instructions, violent and disrespectful youth, and youth stealing to maintain their substance abuse behavior. Conclusion: The study’s findings indicated that the parents of youth abusing substances go through many challenges. Having support from health care workers and family members can help them manage their youth abusing substances.


INTRODUCTION
Substance abuse by youth is a worldwide health problem that negatively affects the wellbeing and the health of the users, their families, and the communities they come from [1]. There is a rise in nonalcoholic substances such as marijuana and methamphetamine in sub-Saharan countries [2]. In South Africa, the use of substances by youth is a growing concern, and it contributes to social ills such as crime violence and can lead to hospitalization [3]. Although the prevalence of substance abuse is high in South Africa, only a small number of people with substance abuse disorders get treatment. The The use of substances in youth starts with smoking, drinking alcohol, using dagga, and sniffing glue. As the abuse of substances continues, the users will experiment with harder drugs [5]. Parents get affected when they see their youth abusing substances, and they do their best to assist their youth in getting out of the substances. They take their youth to the hospital for help and other places to assist their youth in stopping abusing substances [6].
Once the youth is abusing substances or is diagnosed with a substance abuse disorder, the parents have to rearrange their lives. They do their best to adjust to the new normal of taking care of a substance abuser in the house. Some parents manage taking care of a substance abuser well, while others fail because of the challenges they face taking care of their youth abusing substances. This process has become a significant burden whereby parents need assistance from nurses, health care providers, or families [7,8].
Hospitalization of youth because of substances becomes a stressful incident that disrupts the psychological and physical well-being of the parents and the youth abusing substances. It then affects the compliance to medical instructions and recovery in total [9]. The parents of youth abusing substances have expressed the need for help and support because of their challenges in taking care of their youth. They need to be given information on how to take care of their youth who abuse substances and how to manage them when they change behavior and become aggressive and violent. They need emotional support from health care providers, family, and friends. The support that parents can get from health care workers is essential if there is no support from family members [10].

Research Design
A qualitative, explorative, descriptive, and contextual design was used to explore the challenges faced by parents of youth abusing substances. The design allowed the researcher to detail the challenges faced by parents of youth abusing substances.

Study Setting
The study was conducted in selected hospitals in Limpopo Province. The province is situated in the northern part of the Republic of South Africa. The province is divided into five districts: Mopani, Vhembe, Capricorn, Sekhukhune, and Waterberg. The regional hospitals used in this study are Tshilidzini, Jane Furse, Mankweng Hospital, Mokopane, and Letaba hospitals. The units that were used are those that admit youth who abuse substances.

Population and Sampling
The study population was the parents of youth abusing substances in selected hospitals in Limpopo Province. The parents were asked to take part in the study when they visited their young family members or when they came with them to outpatient clinics. The researchers followed both homogeneous and criterion purposive sampling strategies where 14 parents of youth abusing substances were selected to form part of the qualitative part of the study. Purposive sampling was used because the researcher ensured that the participants were typical of the population and met the researcher's criteria. They had the characteristics that the researcher wanted.

Inclusion and Exclusion Criteria
The inclusion criteria of the participants were determined by the following: The participants should be the parent of the youth substance abusers. They must be staying with the youth abusing the substances. The parents of the youth admitted with the primary reason for substance abuse and parents who are available to be part of the study. The exclusion criteria were the parents of youth who were admitted for any mental illness.

Data Collection Procedures
The central question for the study during the interview was: "what challenges do you face caring for your youth abusing substances?" Semi-structured interviews were used to get a clear picture of the participants' views. The interview guide assisted the researcher in asking questions that covered essential aspects of this study. Field notes were written, and a voice recorder was used to collect data from the parents of youth abusing substances.

Data Analysis
The eight steps of data analysis in Tesch's open coding method were used to guide data analysis [11]. The researcher took time to listen to the tape recorder. All information obtained was transcribed verbatim into a script. The transcripts and field notes were read to get a sense of the whole. The data were organized into themes and subthemes. The researchers came up with the most descriptive wording for the themes and subthemes, and the researcher recorded the existing material. A summary of the themes and subthemes was sketched, and the data were sent to the independent coder.

Measures to Ensure Trustworthiness
Trustworthiness was ensured by applying the criteria of credibility, dependability, confirmability, and transferability [11]. Credibility was ensured through prolonged engagement, whereby the researcher took time collecting data until saturation was reached. Dependability was ensured by using an experienced independent coder not participating in the study to code the data collected independently. A consensus was reached with the researcher for the final themes and subthemes. Confirmability was ensured by making an audit trail to ensure that interpretations, conclusions, and recommendations could be traced to their source. In this study, the researchers ensured transferability by clearly describing the qualitative research methodology, including research design, population sampling methods, data collection methods, and data analysis.

Ethical Clearance and Ethical Considerations
Ethical approval was obtained from Turfloop Research Ethics Committee (TREC), number: TREC/305/2018:PG of the University of Limpopo. Permission to conduct the study was obtained from the Department of Health, Limpopo Province (approval number LP 201902_009), Department of Health District offices, and the CEOs of the selected hospitals in Limpopo Province. The participants were briefed about the study. They agreed to be part of the study voluntarily. The researcher made them aware that they have a right to withdraw anytime without any victimization. They were also assured of confidentiality and anonymity.

RESULTS
The presented results reflect the responses of parents of youth abusing substances. Table 1 shows the themes and subthemes that emerged from the study.

Theme 1: Lack of Support
The study's findings revealed that the parents of youth abusing substances lack support when taking care of their youth abusing substances. Three subthemes emerged from the findings: lack of support from the nurses, lack of support from family members, and lack of support from other health care providers.

Subtheme 1.1. Lack of Support from the Nurses
The participants indicated that they did not get support from the nurses in the hospital. This becomes a challenge to the parents as they do not know what to do when caring for the youth abusing substances. One participant said, "I think the nurses do not treat us well. They do not take us seriously. They only focus on themselves when they are in the hospital. They are not available to help you when you want them to help you. They will come to attend to you at their own time. Sometimes they shout at us". The participants wanted the nurses to at least talk with them; this was confirmed by the participant who said, "No, like who has time for us visitors in the hospital. I just see him (my son) and go. Nothing is said or done about me. The nurses just pass us without saying anything". The other participant said, "None of the nurses ever update on his progress, and when I ask them how he is doing, they treat me as if I am proud. I no longer care about the nurses".

Subtheme 1.2. Lack of Support from the Family Members
The participants also stated that they do not get support from their family members back at home. One participant said, "I talked to his uncle. His uncle did not help". The other participants further said, "When I call his uncles to come to talk to him, they refuse to help…". The other participant gave an account that "My in-laws are not helping; they think I contributed to my child being the way he is."

Subtheme 1.3. Lack of Support from other Health Care Providers
The participants wished to have received support from the healthcare workers, but they were never helped. One participant said, "I also talked to the social workers. However, I was not helped…." The other participants also felt that the hospital as a whole is not helpful by saying, "I think the hospital does not have a support system for relatives apart from allowing us to see our children." The other participants said the following about the home-based carers "Home-based carers never come to visit us just to come to see how we are trying to manage him."

Theme 2: Management of youth abusing substances
The study's findings also revealed that the parents of youth abusing substances face challenges at home when they have to take care of their youth abusing substances. The challenges include poor adherence to medication by youth, violent and disrespectful youth, and youth stealing to maintain drug abuse.

Subtheme 2.1. Poor Adherence to Health Instructions
The parents had found it challenging to deal with the youth abusing substances because they were not adhering to the instructions given at the hospital. One participant said, "The nurses told him what he could do to stop the substances, he did not argue with them. He agreed with everything they said, but he continued using substances". While the other participant said, "The nurse may tell him what to do, but it is him who takes back the substances out of the system. When he gets discharged, he still goes back to substance". The other participant further said that "The doctors told him to stop using substances, but he continued. …have you ever seen a person coming back from rehab relapsing at the same time? That meant he was using substances."

Subtheme 2.2. Violent and Disrespectful Youth
The study's findings further indicated that the youth abusing substances are violent and disrespectful, which is a challenge to the parents taking care of them. This was confirmed by the participant who said, "Firstly, has been a change in my child's behavior. He started by being disrespectful". The other participant said, "He becomes aggressive, and sometimes he forgets that I am his mother, he is disrespectful. He becomes somehow like an animal. He does not listen to me". The other participant confirmed by saying, "But he has turned out to be disrespectful and violent. He doesn't even respect the visitors".

Subtheme 2.3. Youth Stealing Things
The parents gave an account of the youth coming to steal to maintain their substance abuse lifestyle. One participant said, "He would come back home to steal for us." While the other participant said, "I am always scared he may steal money at home. When you take a look at him, he is wasted; you cannot explain or understand him". The other participant further stated that "He steals things to feed his substance cravings. He does not steal only for us at home, he steals for other people too".

DISCUSSION
The study wanted to explore the challenges parents face with youth abusing substances. It has been found that the parents of youth abusing substances need support from the nurses. There are many challenges that the parents of youth abusing substances face. Their challenges range from inhospital problems to their problems when they are home.
Everyone must play a role in the lives of the parents and their youth abusing substances while in hospital and post-discharge. The parents of youth abusing substances should also learn how to take care of themselves well so that they will be able to take care of themselves and their youth effectively [12].
The nurses can make the parents' situation more bearable by actively promoting parent-patient relationships. This can be done by displaying professional skills and support. Sharing information and being there for the patients and their parents when they need help. It is important to note that part of the support for the parents of youth abusing substances is sharing knowledge, which is essential for the parents. They can also offer guidance and emotional support [13]. The nurses need to understand the complex needs of the parents of youth abusing substances. Empathy for the parents and the admitted youth abusing substances is the core attribute of the nurses. Nurses should be able to accommodate parents and offer practical support in the form of health education, role modeling, care, support, and clinical leadership [14] Research has indicated that a healthy family can contribute to the well-being of anyone. Positive relationships within the family are linked to the well-being of everyone in the family. The family origin and extended family play an essential role in all aspects of life. Family is a source of financial, cultural, religious, and social support. While families are considered a source of support, there is also proof that families can be a source of stigma due to abuse of substances. Families must support each other to eradicate the effects of isolation, as it gets difficult for parents to cope when they do not have support from other family members [7].
Hospitalization causes stress to the individuals admitted and their relatives. Moving from hospital to home may experience differently for families depending on whether they have a support system or not. The problems may continue after discharge if there is no clear plan to cope post-discharge [15]. The parents need to be supported by health care providers. They need emotional, physical, and information support to take care of their youth abusing substances. This support is essential even if the parents have other support sources, such as family and friends [10]. The relationship between parents/youth abusing substances and health care providers is considered an essential influence on adherence and better wellbeing after discharge [16] Adhering to instructions from healthcare providers is a common struggle for the parents of youth abusing substances [17]. Poor compliance with health instructions such as prescription continues to be a crisis in public health. About half the patients do not take their medications as prescribed, harming their health while increasing public health costs [18]. There are different reasons for the failure of adherence to medication instructions which can be intentional and unintentional. The logic includes side effects or patients feeling like the information they received from the health care worker is inadequate [19]. Caregiver participation in this regard is essential. It can be frustrating for the caregiver when patients, youth abusing substances, do not take medication based on the received instructions [16].
Parents appreciate being respected and being listened to [20], but because of their youth abusing substances, they find themselves being disrespected [18]. The use of substances changes the way people may think or act. The use of substances has been associated with aggressiveness and disrespect in youth [21]. Studies have indicated a correlation between substance abuse and violent behavior [22]. Parents have confirmed that the change in their youth's conduct has resulted from substance abuse, and substances served as a gateway to other dangerous behaviors [23]. Youth abusing substances are likely to be easily provoked or be involved in fights because the use of substances increases the chances of experiencing traumatic events [24].
It is typical for youth abusing substances to be involved in criminal activities [25]. The abuse of substances can lead youth to criminal behavior and be used as a coping mechanism for those with a history of crime [26]. The compulsion to get substances leads some youth to steal to get money for substances. Theft is a common side effect of substance abuse. Substance abusers may steal from their family friends and commit shoplifting from stores [27]. Substance abusers engage in criminal activities such as stealing to maintain their substance abuse lifestyle. Usually, their crime is not significant; they may steal minor things from home or their neighbors [22].

LIMITATIONS
The study was conducted in selected hospitals in Limpopo Province, South Africa. The findings of the study could therefore not be generalized in other settings.

IMPLICATIONS OF THE FINDINGS
The study findings confirm that the parents of youth abusing substances face challenges daily and need support.

HEALTHCARE PROFESSIONALS
Nurses and other health care professionals must be available for the parents and give them information on how to manage youth abusing substances and where to get help when faced with different challenges.

LIMPOPO DEPARTMENT OF HEALTH
The Limpopo Department of Health needs to encourage a thorough preparation of parents for discharge; this will assist the parents in being ready for the challenges they may face after discharge of their youth abusing substances from the hospital.

CONCLUSION
The study has indicated that the parents of youth abusing substances are faced with challenges; some of their challenges are related to support where they feel like they can do with support from nurses, other health care workers, and family members. They also need support in managing their youth abusing substances because they do not adhere to medical instructions, are violent and disrespectful, and steal to maintain their substance abuse life.