Health services for women in outpatient substance abuse treatment

Health Services Research, June, 2005 by Cynthia I. Campbell, Jeffrey A. Alexander

There is growing recognition that the transfer of substance abuse treatment technology from the research community to practice has lagged (Institute of Medicine [IOM] 1998; Brown and Flynn 2002). Such a gap is particularly acute for treatment services for women (Breitbart, Chavkin, and Wise 1994; Finkelstein 1994; Chavkin and Breitbart 1997).

Women present at substance abuse treatment with higher addiction severity and more medical and psychological problems than men (Stein and Cyr 1997; Kandell, Warner, and Kessler 1998; Greenfield 2002). Critics charge that traditional treatment programs are male-oriented and lack services specific to the medical and mental health needs of women (Finkelstein 1994; Nelson-Zlupko, Kauffman, and Morrison Dore 1995; Reed and Mowbray 1999). Gender-sensitive treatment that includes women's services has been shown to be associated with improved outcomes, as measured by increased abstinence, retention in treatment, and improved self-esteem (Marsh, D'Aunno, and Smith 2000; NEDS 2001; Ashley et al. 2003). Failure to provide services that are sensitive to women's needs may dissuade them from engaging or continuing in treatment, and those clients who do proceed with services may receive less appropriate care.

This study addresses an important gap in the literature by evaluating the organizational and environmental determinants of the adoption and implementation of important health services for women by outpatient substance abuse treatment (OSAT) organizations. The extent to which treatment organizations adopt and implement services for women has direct implications for access to care and indirect implications for the effectiveness of care provided to women in substance abuse treatment. "Adoption" indicates whether or not a treatment organization offers a service, while "implementation" indicates whether the technology is actually used. Services must be implemented in order for clients to benefit. Unlike most previous studies, we examine both service adoption and implementation, and analyze how this has changed over time. The study focuses on outpatient programs because they comprise 82 percent of the substance abuse treatment system and are the primary method of delivering services (Horgan et al. 2001).

We evaluate treatment services for women that reflect federal recommendations, as well those found in the substance abuse treatment literature (CSAT 1994; Finkelstein 1994; NEDS 2001). Reproductive services include gynecological exams, contraceptive counseling, and prenatal care. These services are important to women who use substances as they are at higher risk for sexually transmitted diseases, unwanted pregnancies, and lack prenatal care that addresses their substance use. Physical exams, mental health care, and HIV testing are also examined, because women substance users suffer a high burden of mental health problems (Blume 1990), have a quicker progression than men to the physical co-morbidities of substance abuse (Stein and Cyr 1997), and are at high risk of HIV transmission (CDC Fact Sheet 2001).

CONCEPTUAL FRAMEWORK

We use resource dependence and institutional theories to explain the variation in the adoption and implementation of services for women. Resource dependency theory emphasizes how an OSAT unit's dependence on necessary resources determines its selection of service technology. OSAT units are heavily dependent on their environment for financial and nonfinancial (i.e., clients and staff) resources that are critical to their survival, making them vulnerable to the demands of external actors that control those resources (Pfeffer and Salancik 1978). OSAT units' response to those demands is a function of their dependence on the resource (Pfeffer and Salancik 1978). An OSAT unit will be likely to adopt and/or implement women's services if it is pressured by an important external actor that controls important resources.

Female clients and government funding agencies are two key actors for OSAT organizations that are likely to consider women's services important to provide. A highly competitive environment often suggests scarcity of resources and presents OSAT units with uncertainty about the stability of future resources, making them reluctant to provide additional services. Managed care organizations typically focus on saving costs, and are unlikely to encourage the provision of ancillary services.

Therefore, we hypothesize that the percentage of government funds received by an OSAT unit, the receipt of funding for women's programs, and the percentage of female clients will be positively associated with the adoption and implementation of women's health services. We also expect that the perception of a cost-based competitive environment and the percentage of managed care clients will be negatively associated with the adoption of women's health services.

Institutional theory focuses on the response of OSAT units to widely held norms and rules in their environment. OSAT units are embedded in a highly institutionalized environment comprised of government agencies, professional associations, accrediting bodies, and licensing and funding sources (Hasenfeld 1983; D'Aunno and Vaughn 1995). These constituents exert pressures to conform to various regulations, norms, laws, and societal expectations (Meyer and Rowan 1977; DiMaggio and Powell 1983). Key to the survival of human service agencies is the legitimacy and support gained from conforming to these pressures (Hasenfeld 1983). OSAT units depend less on the technical proficiency of their work, which is difficult to demonstrate, and more on conformity to dominant belief systems and institutional rules in their environment. If an OSAT unit gains legitimacy and support from constituents by adopting and implementing women's services, it is more likely to do so (Hasenfeld 1983).