This study sought to explore service providers' perspectives in aftercare service provision for PWSUD in a rural district. Service providers reflected on the state of aftercare services, observed barriers, acknowledged existing enablers and contributed to recommendations for aftercare service provision. Four themes emanated from the data sets, namely, (i) reflections of the interactional state of aftercare services and program content, (ii) identifying existing barriers to aftercare service provision, (iii) situating systemic enablers to aftercare service provision, and (iv) associated aftercare system recommendations.
Theme 1: Reflections on the interactional state of aftercare services and program content
Table 2 Theme 1 with Subthemes and Categories
Theme 1: Reflections on the interactional state of aftercare services and program content
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Subthemes
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Categories
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Inadequacy of aftercare service provision
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• Superficial aftercare services
• PWSUD lost within the system
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Notable effective and successful aftercare intervention
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• Success story 1
• Success story 2
• Success story 3
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Validation of the types of aftercare services
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• Home visits
• The essentiality of family centeredness
• Family reintegration services
• School visits
• Individual counselling
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Recommended aftercare program content
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• Affirming family centeredness
• The pertinence of support groups in aftercare
• Reintegration services of PWSUD
• Aftercare to address vocational needs
• Relapse prevention
• Chronic orientated aftercare
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Inadequacy of aftercare service provision
Service providers reflected on the inadequate state of aftercare in the district. In this rural district, the aftercare wasconsidered poor, executed within a fragile system, and if provided, lacked continuity and was deemed superficial at best, resulting in PWSUD being lost within the system.
I can say that there is this missing point of follow up or continuity of care. (Thandazile, Fieldwork and Implementation)
There is still a lack of aftercare services to the people who have completed rehab, when they go out. Yes, they are still lacking aftercare so they find themselves coming back now and again in rehab because there is not much support for them…Yes, however, even the DSD is supposed to run an aftercare program… Ya they are supposed to because it is not happening but they have to (laughs). (Carol, Management, Coordination and Control)
They get discharged from rehab but they get lost we do not see them then they show up when relapsed. (Jazzman, Fieldwork and Implementation)
We can’t even find her. They are still hunting for her. (Mngomezulu, Management, Control, Coordination and Implementation Control)
Notable effective and successful aftercare intervention
Service providers reported limited successful aftercare intervention i.e. among forty-five service providers, only three aftercare success life stories reported.
Story 1
But fortunately, I keep checking with the lady and she’s drawing closer. But I’m doing a lot of aftercare for the teenager, and fortunately the teenager has gone back to school this year and apparently, he’s doing well with the mother, though there are some elements of actually relapsing along the way. But with the care of the mother and also myself, we support. I also visit the school when I’m going to the clinic and stuff, just pass by the school just to check with the teachers. There’s a lot of improvement. (Vika, Fieldwork and Implementation)
Story 2
I think I visited the family because they knew that the patient had to stay for three months but I think he stayed for months. Then he had to explain at home why he came back earlier. So, I was the first one who was to talk to the family not to judge the patient because I knew that he had potential. He’s the one who came to my office and said no I’m tired of using drugs, so I want to stop now. Then we tried to apply for rehab at Newlands. Then when he came back the family was disappointed, but I had to talk with the family, no he’s okay provided we give him the support. Because he had potential, we were communicating now and again checking where he is, what he’s doing, yeah. (Musa, Fieldwork and Implementation)
Story 3
And I said to them no, it’s a collective work for us as therapists and also the institutions. The person, I mean even now I saw him, he’s functional and in the hospital where he is working. He is fully functional, I was actually doing some aftercare follow up with the supervisor in the ward that he is working and he’s doing exceptionally well. Even in the training, where he was supposed to go. They were taken to further their training in nursing and he was doing well. Even passing with flying colours, even as tutors in this college. So, you can really see that how substance abuse can rob us of our potential. (Vika, Fieldwork and Implementation)
Validation of the types of aftercare services
There were inconsistencies in the provision of the limited aftercare services pertaining to home visits, family intervention, family reintegration services, school visits and individual counselling in this rural area.
Preparation for the environment, home visit to the family to strengthen support system. Counselling for family and the affected member. Then a CCG (Community Care Givers) because we cannot always be there then if the CCG identifies the problem they report to us. (Grace, Fieldwork and Implementation)
We do individual counselling, they come here at the center. (Joel, Fieldwork and Implementation)
Recommended aftercare program content
The essentiality of family centeredness
Service providers recommended that aftercare be centered on the family, and the family should know their essential role in aftercare.
As soon as they know that they have a more important role to play than the treatment center, they will then take part in a full way, in a fully pronounced way of the aftercare service. (Mngomezulu, Management, Control, Coordination and Control)
Because it’s also very important to strengthen family support because they stay with the family they don’t stay with us as health care workers. So, ours just ends here in the office, but I think we need to strengthen the family support. Even if we are not there. But the family will give support to the client. So that’s very important. (Musa, Fieldwork and Implementation)
Family-centered aftercare should address broken relationships within the family.
There are broken relationships because the family is affected, the society is affected, the family does not want this person back home. The society does not want this person back. (Zinhle, Management and Control).
The pertinence of support groups in aftercare
Service providers reflected on the need for support groups during aftercare which were absent in their district. In addition, suggested that support groups should include family members because they also need support and a space to share their experiences.
I also thought of support groups where they can talk about their experiences. This must include family because you find that families are in denial and some rely on traditional healers. So, if they come to support groups they can also learn as a family. (Nickita, Fieldwork and Implementation)
Revisiting reintegration services in the system of care
Service providers maintained that reintegration services must endeavor to comprehensively reintegrate PWSUD within their context of family, workplace and community.
Yes, of course aftercare is good because we can even report to employment centers where the person was employed, that the person has the right recommendation, that they must take him back. Another thing that makes (cause) failure is the companies, the workplace that employed this person, the negative attitude of taking this person back because he could have done a lot of bad things before he was sent to that place. They say “no we cannot take him back” in spite of the person being more knowledgeable than the people who are now replacing him. (Mngomezulu, Management, Control, Coordination and Control)
However, reintegration is faced with a number of barriers, including stigmatization, therefore service providers should work with families and communities to facilitate reintegration.
The referral social worker needs to work with the family as well as the society. This person has been through help so please give him a chance, a second chance person but we will be working with him in the recovery process because the recovery is not a year or two, it is a process. (Zinhle, Management and Control)
Contextualizing the realities of vocational needs
Service providers admitted that most PWSUD have unmet vocational needs such as unemployment, job placement and skills development.
Sometimes there are just basic issues, unemployment. Which are the things that you cannot do easily but at the local offices they have other programs like program 5. Then we said link them. (Zinhle, Management and Control)
Service providers were of the view that the collaboration of departments in job placement could address unemployment needs.
Departments should be able to talk and say so and so has been discharged, can we find a placement? (Vika, Fieldwork and Implementation)
Additionally, addressing vocational needs should include skills development.
I think maybe it’s not only counselling that they need; they also need some skills, give them skills because they use drugs most of them and because they are staying at home, they are doing nothing. (Musa, Fieldwork, Implementation)
In the aftercare program, if we can involve skills that we can do with them. That will create job opportunities for them. (Carol, Management, Coordination and Control)
Sustaining relapse prevention
Relapse prevention was recommended through engaging in recreational activities, skills development and regular and consistent monitoring.
It becomes easy for them to relapse if there is nothing that they are doing that is keeping them busy. Even playing soccer or some activities, being involved in other activities, it takes their minds away from drugs. (Carol, Management, Coordination and Control)
I think maybe if we do have a center, maybe a recreation center where they will come maybe once a week to have a support group there with them. (Thando, Fieldwork, Implementation and Coordination)
Service providers also recommended aftercare that is chronic-orientated, which offers continual support or lifelong support for PWSUD.
Another thing aftercare should not have a specific duration we must not let go of our clients but live with them and support them until they die (Joel, Fieldwork and Implementation)
They will always need intervention, regular follow-ups to prevent relapse. (Vela, Fieldwork and Implementation)
Table 2 Themes 2, 3, & 4 according to VSM levels
Beer’s VSM Levels
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Theme 2
Identifying existing barriers to aftercare service provision
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Theme 3
Situating systemic enablers to aftercare service provision
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Theme 4
Associated aftercare systems recommendations
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Implementation level
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• Internal Motivation of PWSUD
• Family denial
• Family’s limited knowledge of recovery process
• Stigmatization of PWSUD
• Poor community participation/partnerships in rehabilitation
• Long waiting lists in ITCs
• Unavailability of medication for withdrawal
• Lack of education and training about SUD for service providers
• Limited transport for service providers
• Poor inter-sectoral collaboration
• Lack of funding for aftercare services
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• Team approach at hospitals and clinic level by DoH
• High level of motivation of a PWSUD
• Strong family support
• Telephonic follow-ups from ITCs
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Case manager or coordinator is required to coordinate aftercare services
Teamwork in proving aftercare services
• Teamwork should be facilitated through clinic card and CCG
• Community partnerships facilitated through education cognizant of the cultural context.
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Coordination level
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Poor communication among stakeholders rendering services within the same community
Limited awareness of each stakeholder’s roles, responsibilities and scope of practice.
Poor communication between ITC & referring service providers
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The necessity of collaborating with community caregivers.
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Encouraging inter-sectoral collaboration among various sectors
Inter-sectoral collaboration should be facilitated through war-room
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Control level
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Evaluation of SUD Services: poorly managed and monitored
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Maximizing on war-rooms
Considering a Ward-based approach
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Strengthen monitoring and evaluative mechanism for aftercare services.
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Intelligence/
development level
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Limited accountability and reporting of NGOs to local institutions
Absence of aftercare statistics in Provincial reports
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Negligible support for SUD programs
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Accountability of NGOs should also be at institutional level i.e. DSD facilities or hospital.
Encouraging comprehensive details of SUD in reports
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Policy level
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SUD programs not prioritized by DoH and DSD
NGOs reporting renewal at policy level only
Lack of standard of care
Lack of policy awareness
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Policies in place
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Revisiting the accountability of NGOs
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Themes 2 – 4: Identifying existing barriers and situating existing enablers to service provision and associated aftercare system recommendations (Table 2)
To deliver the aforementioned aftercare content, a comprehensive understanding following the interrogation of all components of aftercare service provision should be assessed, bearing the stakeholders in mind. In this study, different levels of service provision, as per the Beer’s VSM, namely implementation, coordination, control, intelligence/development and policy level, were explored [28). Therefore, it is essential to classify these barriers and enablers at different levels to understand the contextual implications comprehensively.
Implementation level
Service providers noted that some PWSUD lacked internal motivation towards recovery. Although service providers did not mention a highly motivated PWSUD as an enabler, the success stories for aftercare indicated that highly motivated PWSUD enabled service provision.
He’s the one who came to my office and said no I’m tired of using drugs, so I want to stop now. (Musa, Fieldwork and Implementation)
There were several barriers to the provision of aftercare to the family, namely family stigmatization, family denial and lack of knowledge regarding the recovery process.
The family understands that this is a long-term problem, it’s not, we don’t fix it at the hospital. You’re admitted, you’re here and it’s expected that they will be fine, why are they not getting better? … Yes. You know there’s a, I find the families always come back, ‘why are they not getting better?’ ‘Why are they not stopping?’ And trying to make them understand the lifestyle change and it’s for the rest of their life. They may have to deal with this and the dynamics of the family that has to change. (Dr K, Fieldwork, Implementation and Coordination)
Service providers identified barriers at the community level, such as stigmatization of PWSUD and poor community participation/partnerships in rehabilitation.
I feel like not many people meet, so when you see a patient, they might come with psychosis, but they’ve only met their previous abuser so the stigma about being a substance abuser is still quite strong here, they are not open to talk about it. (Zakithi, Fieldwork and Implementation.
Community partnerships were expressed as necessary in facilitating education that is culturally and contextually specific.
I believe there can be educational workshops … You’ve got to equip them with knowledge and skills and how to deal with… but it must be culturally based, whatever information you are giving it must be sensitive to culture, cultural norms and values of that group because each group has got different norms. It doesn’t mean because you’re a Zulu, your norms are the same … Clan praises! (Laughs). (Mngomezulu, Management, Control, Coordination and Control)
Service providers observed the lack of resources as a barrier in their respective sectors. These include staff shortages, a lack of ITCs in their district, lengthy waiting lists in ITCs situated in cities, unavailable medication for withdrawal symptoms, limited transport for home visits, and a lack of funding for aftercare services for NGOs.
There is no funding allocated to aftercare, so even if you want to do aftercare, there is no budget. (Palesa, Fieldwork and Implementation)
From my department I felt we lack the constructive use of their time, and it will be very good to have groups. But due to a limited number of us, we don't have the human resources to carry through (Zakithi, Fieldwork and Implementation)
Service providers also identified an urgent need for the training of social workers at the district level on SUD service provision in a South African context.
One of the challenges we have is that the support for continuity of care as well as training, education, regarding how we proceed with continuity of care particularly with substance abuse, we do find that the Department of Health doesn’t really focus much on that. (Dr K, Fieldwork, Implementation and Coordination)
Although service providers did not overtly express an interdisciplinary team approach as an enabler for service provision, service providers at some DoH institutions reported more comprehensive services at hospitals and clinics, using mental healthcare (MHC) teams. MHC teams enabled more robust communication and collaboration among disciplines within the same institution. The opinion of service providers is that poor communication among sectors could be minimized through promoting teamwork that can be facilitated through clinic cards and involvement of community caregivers (CCG).
CCGs are community-based and well acquainted with service users from the same community.
We have mental health teams so we are integrated into the hospital. (Nickita, Fieldwork and Implementation)
Now it is better, we work with SORD (NGO), they are funded by DoH to provide mental health services. They do much treatment but focus on empowerment; they do follow up and support groups… We write referral letters to them. (Grace, Fieldwork and Implementation)
We also do lots of follow ups on the CCG’s since they are the ones who actually do a lot of baseline visits to the families to check as to if there is any improvement. Though sometimes you’ll find that the family will not give you all the information, but the CCG’s you’ll find they’ll give you all the information as to what is happening, is there any improvement, any changes that are there. (Vika, Fieldwork and Implementation).
Using the Clinic Card as a tool to communicate. Because everyone writes on this card even the CCG. Then we can all see what is written. Because when we do home visits we sometime go with the SW, OT and Psych nurse. I don’t know how realistic is that because we do not know. (Thobile, Fieldwork and Implementation)
Coordination Level
Service providers expressed that there is poor coordination of services characterized by poor communication and lack of monitoring.
I am saying when they release a person from rehab sometimes, they do not tell us and that is a problem... We will only see a person when he is brought back when he has relapsed; this person, when was he released? That is another big problem... Uh… the communication between the rehab center and the treatment center and the treatment organization and the NGOs is not well monitored. (Mngomezulu, Management, Control, Coordination and Control)
There is also poor coordination within the same sector, which indicates poor cooperation and interaction of sub-systems. There is miscommunication between ITCs (sub-system) and service providers at community level (sub-system).
Even when they go to rehab they go there but when discharged, all the stakeholders I was telling are not aware. They go back home with no support. (Thobile, Fieldwork, Implementation and Coordination)
We still do not get any feedback unless a social worker from here is still liaising, client checking, that are you still okay; or maybe sometimes the client phones and “how are you doing”? “I am doing 1, 2, 3, 4,5 - giving the social workers feedback. (Carol, Management, Coordination and Control)
To achieve a well-coordinated system of care, service providers were of the view that a case manager is required to assist with coordinating the service and facilitate inter-sectoral collaboration. The service providers revealed that existing collaborative structures such as school health teams and local drug action committees enabled the collaboration of stakeholders in prevention programs, but not in any treatment interventions.
We work together with the school health team as well as with the local drug committee where we go to schools to do health education like awareness. (Thandazile, Fieldwork and Implementation)
Control level
Service providers acknowledged the inadequate monitoring of SUD services and the absence of statistics submission at the district level.
No M and E for aftercare, even SUD we report on how many admitted. (Nonhle, Coordination and Control)
We do it on a small scale. It is touch and go … we group them in mental health stats, just reporting how many were SUD and how many were schizophrenic. (Thobile, Fieldwork, Implementation and Coordination)
No, we do not take any statistics of aftercare. Actually, nothing is reported about aftercare. (Sydney, Fieldwork and Implementation)
There should a very strong monitoring and an evaluation of SUD programs. More details for aftercare in the reports. (Bhekani, Management, Coordination, Control and Development)
The existing program of war rooms (a meeting of multiple stakeholders working in a ward/a a particular community) appears to be an enabling mechanism for collaboration in prevention strategies.
We use war rooms to communicate with other stakeholders where we identify cases together. (Nonhle, Management, Coordination and Control)
I believe we must also be using the war room groups. Yah. The war room groups because they are the ones that are going to report back to us. (Mngomezulu, Management, Control, Coordination and Control)
In addition, DSD recently implemented a ward-based approach (each or several social workers are allocated to a ward to render all services) to service delivery which was said to be a facilitator for stakeholder collaboration.
Ward-based approach is helping in a way although there are still challenges. (Joanne, Coordination, Control and Intelligence)
Intelligence level
Little support of SUD programs, characterized by inadequate provincial reporting tools, was noted as a barrier to service provision.
There is support for other programs from provincial but very little for SUD services. Aftercare is not even recorded in monthly stats. (Nonhle, Management, Coordination and Control)
The reporting tool does not include aftercare at all. It does include the number of people sent to rehab though. SUD is not a priority… You find that we only report how many have been to rehab and it is not monitored. No statistics collecting it, so even when they have done it there is nowhere to report. (Thembeka, Coordination and Control)
Service providers maintained that the accountability of state-funded NGOs should also be at local institutions.
They run away from accountability, because these NGOs are funded by us … They are funded by Health, they are funded by DSD. (Vika, Fieldwork and Implementation)
Additionally, service providers recommended that reports include SUD details such as aftercare and encompass the different/joint stakeholders instead of reporting in silos.
Then by doing that, when you come to Province and report, it’s collective. (Vika, Fieldwork and Implementation)
Policy level
There was a noticeable lack of policy awareness on the service delivery (implementation) level, compared to service providers at the management level. As a result, the implementation service providers were unaware of specific policies guiding aftercare.
No, we don’t have a specific standard. I can’t remember how I discharge them from or they discharge themselves, really. But I think once a month. (Musa, Fieldwork and Implementation)
No aftercare program we follow, no, no, there is no specific program. (Jazzman, Fieldwork and Implementation)
In addition, service providers expressed that the DoH and DSD do not prioritize SUD programs. Instead, service providers are under pressure to meet targets for other competing programs.
We have a lot of competing priorities. You see it has targets that are big very big, so social workers are chasing after them because they will report on them. So psychosocial services take a back seat because they will not report on them. (Joanne, Coordination, Control and Intelligence)
Service providers at DSD expressed their frustrations about meeting targets of other programs, whilst for SUD, they were required to meet targets of prevention programs in the form of the number of people reached through awareness campaigns. In addition, the extensive reporting was time-consuming as opposed to rendering comprehensive services to their different client population. Notably, the targets they had to meet interfered with their duties.
Even the community knows us that we no longer work but we are pushing targets. It is hard because if you do not meet the target you have to explain why. So, SUD takes a backseat. (Joel, Fieldwork and Implementation)