Time to Get Help? Help-Seeking Process in Latin American Hospital Patients with Alcohol Use Disorder

Alcohol Use Disorder (AUD) is one of the most harmful conditions associated with consumption. Despite a high level of consumption and an elevated number of people living with an AUD, evidence from help-seeking processes in Latin America is scarce and absent in Argentina. This paper aims to describe reasons for delaying and starting help-seeking, the process of problem awareness, and the years elapsed between drinking initiation, problem awareness, and help-seeking, as perceived by a clinical, non-random sample of people with AUD (n = 51). The most frequent reason for delaying help-seeking was not believing there was a problem. The most frequent motivators for seeking help were having physical or psychological problems due to use and repeated attempts to reduce or stop use. The outcomes of this study can be useful for designing interventions to reduce help-seeking barriers and facilitate access to treatment.

On the other hand, there may be factors that facilitate a faster recognition of alcoholrelated problems in AUD patients. Studies have found that the decision to seek treatment usually follows reasons such as comorbidity with other diseases, having a previous talk with a health professional, or reporting more negative consequences from substance abuse (Kaufmann, Chen, Crum, & Mojtabai, 2014;Watkins et al., 2018); these studies also point to disparities in perceived barriers by ethnic groups. In consequence, information regarding barriers and facilitators of the help-seeking process is not negligible but fundamental for the design of culturally appropriate fit interventions for this vulnerable population and their communities.
Despite a high level of consumption and a considerable number of people living with an AUD, little data regarding the help-seeking process has been found in Latin America and particularly in Argentina, where alcohol consumption is one of the highest worldwide (Poznyak & Rekve, 2018). Furthermore, drinking is greatly tolerated in several groups, including vulnerable populations such as women and youth (Observatorio Argentino de Drogas, 2017). Therefore, this paper aims to describe treatment-seeking barriers and motivators, as perceived by a clinical sample of people with AUD who sought help in one hospital's alcohol treatment unit in Argentina. Specifically, we will describe the reasons for delaying help-seeking, the main alcoholrelated problem motivating help-seeking, the first alcohol-related problem acknowledged, and the years elapsed between drinking initiation and problem acknowledgment, and between problem acknowledgment and the actual help-seeking.

Sample characteristics
Fifty-one patients with AUD who sought help in a specialized unit for hepatology and alcohol treatment were interviewed in 2014 and 2018. This unit is the only one of its kind in the city of Mar del Plata, Argentina, and depends upon a large regional public hospital. Participants were referred by the unit's physicians when they were seen as capable of giving informed consent and taking part in the interview. The sample was, thus, a clinical non-probabilistic sample. Six participants were females (12%), and 88% were males. Ages were between 31 and 74 (M=52.96, DS=9.98), and almost 40% were divorced or separated. The majority of patients were selfemployed, underemployed, with precarious jobs (42%), or unemployed (35%), and only 3 (6%) were salaried workers. The rest of them (17%) were retired.

Study Design and Data Analyses
This study combines qualitative and quantitative (descriptive) methods. Once the patient received medical attention from the unit's physician, they were invited to participate in the study.
Written informed consent was requested, and an information sheet about the study's characteristics, including the confidentiality of collected data and how to contact the researchers, was given to the patient. The project met the requirements of the Ethical Committee of the Alcohol-related problems: the first problem to be acknowledged and the main problem motivating help-seeking. After screening for AUD criteria with the Composite International Diagnostic Interview (CIDI), which yields diagnoses compatible with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-10) , we asked participants to remember which consequence of alcohol they had experienced first, and which had motivated help-seeking. The list comprised of: role impairment, craving, hazardous use, tolerance, larger or longer use than intended, not being able to stop drinking once started, repeated attempts or strong desire to reduce or stop use, time spent using, reducing activities in order to use, withdrawal, physical problems due to use, drinking despite an underlying illness, psychological problems due to use, interpersonal problems, and legal problems. We read the criteria once again, one by one, to aid the process. If they wished so, they could add an item not listed.
Reasons for delaying help-seeking. Following the former question, we asked: "Which is the main reason for not seeking help for alcohol-related problems until you had a particular problem?" Responses were first categorized into the three categories developed by Verissimo and Grella (2017): structural, attitudinal and readiness to change. They were then coded by two experienced researchers, yielding a very poor kappa value (kappa=.07, CI 95% 0-0.27). Hence, we created our categories derived from the data.

Years elapsed between drinking initiation and problem acknowledgment, and between
problem acknowledgment and the actual help-seeking. We asked what their age was when they first initiated drinking, what their age was when they started to realize that there was an alcoholrelated problem and their age when they finally sought help. Later, we computed the time difference between these events and performed descriptive statistics for the resulting variables.
We performed content and kappa analyses for the categories of reasons for delaying helpseeking. Two experienced researchers (RP and MC) rated the categories. Quantitative descriptive analyses of all the variables were also made.
Others (12%, CI 95% 4-22) reported religion, hitting bottom, work, having put a third party in danger, friends, and family, and one participant who firmly disbelieved in the occurrence of any problems reported none.

Reasons for Help-Seeking Delay
Forty-six participants gave reasons for why they had delayed help-seeking. Content analyses yielded seven categories help-seek of these reasons: 1) lack of information on the problem or where to seek help; 2) lack of awareness of the problem or its seriousness; 3) not wanting to quit drinking; 4) lack of support; 5) distrust; 6) feeling that the problem could be managed on their own; and 7) being used to the problem. There was an adequate inter-rater agreement for these categories (kappa=.74, CI 95% .57-.90). The main reasons for delaying helpseeking were: lack of awareness about the problem or its seriousness (50%, CI 95% 36-65), not wanting to quit drinking (20%, CI 95% 9-33), and feeling that it could be managed on their own (17%, CI 95% 6-28); less frequently reported reasons were: lack of information about the problem or where to seek help (6%, CI 95% 0-15); lack of support from significant others (2%, CI 95% 0-6); distrust about professionals (2%, CI 95% 0-6); and being used to the problem (2%, CI 95% 0-6).

Time Gap between Drinking Initiation, Problem Acknowledgment, and Help-Seeking
The mean age and range (in years) of drinking initiation, awareness of problems, and help-seeking in AUD patients are presented in Figure 1.
The mean age at which drinking was initiated was M=14.44 (CI 95% 13.09-15.91), DS= 4.16, ranging from five to 25 years. When asked about the age in which they became aware of an alcohol-related problem, eleven patients (21%) stated they did not believe they had a drinking problem, despite the number of criteria met, having answered positively to the question about the main problem that motivated help-seeking, and the actual search for specialized treatment.

Discussion
We discuss two aspects of these results: first, age of drinking initiation, first clinical manifestations, and help-seeking; second, help-seeking motivators and treatment barriers.
Our results indicate an early age of drinking initiation, agreeing with previous reports from Argentina (Pilatti, Fernández, Viola, García, & Pautassi, 2017), and a window of around 30 years between drinking initiation and the awareness of an alcohol-related problem. In agreement with our findings, other studies in the U.S. have also found long gaps between the onset of substance-related problems and help-seeking, using a similar methodology (Chapman et al., 2015). Therefore, adulthood seems to be the ideal time to study and intervene in denial, perhaps improving the self-recognition of alcohol-related problems (Glass, Grant, Yoon, & Bucholz, 2015). Besides, infancy, adolescence, and young adulthood may provide a window of opportunity to assess, avoid, or reduce alcohol intake (if started).
Linked to this finding, the awareness of problems came along with adulthood, almost 27 years after drinking initiation, when problems may have progressed to more severe expressions of AUD. The awareness of, for instance, a physical problem related to drinking which prompted help-seeking, came almost a decade after the acknowledgment of alcohol-related problems.
Nearly one-fourth of the patients referred to interpersonal problems with family members as the first alcohol-related problem they acknowledged. Significant others are more aware of the consequences of drinking, and conflict may arise from confrontation with a family member with AUD. Additionally, family relations are highly valued among people of Latin American backgrounds, such as Argentineans (Lansford et al., 2016), likely making interpersonal problems arising from drinking more prominent than in other areas. Other problems among the first to be acknowledged were not being able to stop drinking once started, repeated attempts or strong desire to reduce or stop use, and withdrawal symptoms. These three problems may be part of the experience of losing control over drinking, or what has been called abnormal drinking behavior (Conde, Brandariz & Cremonte, 2016), which likely constitutes the core of alcohol dependence (Thombs & Osborn, 2019).
Regarding help-seeking and treatment barriers, the main alcohol-related problem motivating help-seeking was continued use despite health problems. This implies not only loss of control over drinking, but also the recognition of an inability to reverse it on their own, even when there is evidence of impairment to physical health. We also found a lack of awareness of the problem as the main barrier for help-seeking. Therefore, even though they could recognize some alcohol-related problems, the main reason for not seeking help was that they did not know or thought they had them. Such a phenomenon may be linked to cognitive distortions including self-deception (e.g. denial), which is in agreement with other studies that have also found denial as the main barrier for help-seeking (Owens, Chen, Simpson, Timko & Williams, 2018).
Tackling denial may be a good way of shortening the time between the awareness of problems and help-seeking; however, denial is a complex construct, and evidence regarding interventions to address it are sparse (Thombs & Osborn, 2019). Nonetheless, some authors have pointed out that denial and self-deception can be reduced with 12-step programs and/or abstention from alcohol (Martínez-González, López, Iglesias, & Verdejo-García, 2016).
An important limitation of our findings is the retrospective nature of the study.
Researchers have advised caution in retrospective studies with patients in early recovery (e.g. Krenek, Lyons & Simpson, 2016) since memory and other cognitive functions might be affected.
However, others (e.g. Ros-Cucurull et al., 2018) have noted an improvement in many mental processes within the first months of recovery, as was the case with many of the patients participating in our study. Another limitation to our findings is that other psychological comorbidities (either through additional axis I or axis II disorders) (American Psychiatric Association, 2013) were not explored, although they might play a role in the help-seeking process. Despite limitations, this is, to the best of our knowledge, the first description of helpseeking processes in Latin American people with an Alcohol Use Disorder.
Results presented here characterize AUD and examine treatment barriers as perceived by Latin American patients. Our findings highlight the need for regular AUD screening in primary health care settings, considering the variety of obstacles patients found for seeking treatment. The long gap in time between drinking initiation and awareness of problems evidences the need to implement public policies to change social norms regarding drinking and drinking problems among Argentineans. Figure 1. Mean age, CI 95%, SD, and range (in years) of drinking initiation, awareness of problems, and help seeking in AUD patients of an alcohol outpatient hospital unit (below). Percentage of drinking problems that were first acknowledged and percentage of problems that lead to help seeking (above). CI: confidence interval; SD: standard deviation; AUD: alcohol use disorder.