The overall aim of the present study was to investigate the associations between stigma, preferences for help-seeking, and preferences for treatment for AUD in a general population sample. Specifically, the study examined associations between: 1) stigma and preferences for type of help-seeking; 2) stigma and preferences for types of treatment; 3) stigma, preferences for types of help-seeking, grouped by level of alcohol use; 4) stigma and preferences for type of treatment, grouped by level of alcohol use. We found that perceived stigma was related to preferences for where to seek help and treatment, and that the individual’s level of alcohol use also had an impact. Our findings will be discussed in detail below.
Preferences for help-seeking
In our study, based on a survey performed among the general population, a lower perceived stigma was associated with a higher probability of stating a preference for seeking professional help and a higher probability of stating a preference for asking someone close for help. Sub-analyses, where the participants were grouped by level of alcohol use, still identified an association between lower stigma and a higher probability of a preference for seeking professional help, but not an association with a preference for asking those closest to me for help. These results indicate that willingness to seek professional help is closely related to stigma, and that a high level of stigma may contribute to a reluctance to, and lower preference for, seeking professional treatment. This is in line with the research on barriers to treatment, which shows that the stigma associated with AUD is an important barrier to treatment-seeking [17,18,19]. Thus, in order to reduce the current treatment gap, there is an urgent need to reduce the public stigma attached to AUD. Educational-based interventions and social contact interventions have shown to be effective in the short term, both for reducing stigma associated with mental health in general and SUD in particular [28, 29]. However, there is a need for high qualitative research in this field and studies on effects over a long-term follow up. The use of continuum beliefs for messages around treatment-seeking for AUD (e.g. framing AUD as part of a continuum rather than a dichotomous disorder) could be especially relevant for future studies, as it has also been found to reduce stigma for psychiatric disorders . There is also evidence that messaging, applying a continuum beliefs model of AUD compared to a binary belief model, can increase problem-recognition, which in turn can improve treatment-seeking .
Stigma may have different mechanisms and impose different types of barriers to help-seeking depending on the type of help – e.g., seeking professional treatment or informal support from the social network. Regarding stigma and its association with seeking informal support, it is known that health-related stigma in general, but not specifically for AUD, is associated with not telling others and fear of social rejection and judgment . Moreover, the present study also showed that public stigma in the general population decreases the preference for informal support-seeking for AUD, when the issue is considered hypothetically. Among individuals in treatment for SUD, higher stigma is found to be associated with lower perceived social support [9, 33]. Similar findings are made among individuals living with HIV . It is, however, unknown to what extent these findings illustrate a reciprocal process with decreased social support, or rather withdrawal from social support, possibly because of fear of social rejection.
A preference for avoiding help or treatment from the outside, and rather trying to change on one’s own, was not associated with the level of stigma nor seemingly affected by one’s own alcohol use, which may not be surprising. Epidemiological studies show that many with AUD recover without seeking help , although treatment-seeking has been found to increase the rates of recovery [36, 37]. The wish to handle alcohol use on one’s own, has also been reported as a reason for not seeking treatment for AUD [18, 38]. The present study suggests that there are mechanisms other than stigma, associated with this preference. A qualitative Swedish study showed that a contributing factor to the wish to handle one’s alcohol use on one’s own was the perception that AUD was a bad habit, which could be altered by changes in everyday life, rather than seeking treatment . This indicates that the personal framing and understanding of AUD contributes to preferences on how to solve it. This is also in line with other studies, showing that the choices of treatments strongly relate to the perceptions of the causes of AUD [39, 40].
Regarding preferences for where to seek treatment, the results of the present study showed that both lower and higher stigma scores were associated with a higher probability of a preference for consulting a GP for treatment. In the sub-analyses, when alcohol use was also adjusted for, the association between lower stigma and a higher probability of a preference for consulting a GP was also found. These findings emphasize the crucial role that GP’s and primary care play as a cornerstone in Danish health care . It also suggests that the trust in GPs is high, and that GPs are expected to play an important role in addressing and treating AUD. Other studies have also found strong support for routinely asking questions about alcohol use in primary care . Thus, GPs play a vital part in recovery from AUD [43, 44].
There were no associations between stigma and preferences for seeking treatment through social services, the Internet and by telephone, even when the level of alcohol use was taken into consideration. This is surprising, considering that a previous study on treatment preferences showed that Internet support and telephone helplines were preferred alternatives for assessment and guidance to treatment . Moreover, it is often possible to access Internet support or telephone helplines anonymously, which has been reported to lower the threshold for seeking support for stigmatized health conditions as AUD [45, 46]. A possible explanation for this finding may be that the treatment-seeking process—in itself – is associated with stigma. Non-treatment-seeking adults with AUD have reported that the need for treatment is, in itself, shameful and a sign of failure [18, 45]. It has been found that seeking treatment is associated with a perceived change of identity toward a stigmatized stereotype of someone with AUD [18, 45]. Similar observations have been made among individuals seeking treatment for SUD . This could be seen as an example of a self-stigma process, and the results from the current study suggest that, in relation to stigma, the choice of where to seek treatment is secondary to the decision to seek treatment. Future studies should investigate this further.
Strengths and limitations
An important limitation is the use of self-report measures on topics such as stigma and alcohol-related questions, which can be perceived as sensitive by the participants. Sensitive topics pose an increased risk for giving socially desirable answers. In order to reduce the risk of bias, stigma was measured with a questionnaire that emphasizes differentness, which is considered to impose less risk for biased answers compared to other measures of stigma [48, 49]. However, we acknowledge a lack of psychometrically sound and brief instruments to measure public stigma in general, and public stigma associated with AUD specifically. This is a potential threat to the validity of the measure of stigma in this study, and an important limitation.
Another limitation is that the current study only measured preferences for different treatment settings. It is possible that factors other than the setting are important, such availability, or messages about treatment goals – reduced alcohol use, or abstention only.
AUD, stigma and help-seeking are complex phenomena, where synergistic effects between these and factors such as socioeconomic position, gender, and age are to be expected. Moreover, previous studies have shown that individuals familiar with AUD, and individuals with lived experience of AUD, are less likely to endorse stigmatizing attitudes towards others with AUD . A strength of the current study is that these factors were included, together with a large sample size. A limitation is the age range among the participants, between 30 and 65 years, which hampers the possibilities to generalize the findings to other groups. Another is the lack of information about the proportion of invited participants who answered the survey.