gender differences in treatment needs, services, utilization, and outcomes karol kaltenbach, phd...
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Gender Differences in Treatment Needs, Services, Utilization, and Outcomes Gender Differences in Treatment Needs, Services, Utilization, and Outcomes
Karol Kaltenbach, PhD
Department of Pediatrics
Jefferson Medical College
Thomas Jefferson University
APA Disclosure StatementAPA Disclosure Statement
This is to acknowledge I have no relationship with any manufacturer of a product or service I intend to discuss.
OverviewOverview
History of specialized services for women
Assessing comprehensive needs of women
Complexity of needs and treatment outcomes
History of Specialized Services for WomenHistory of Specialized Services for Women
NIDA 1974
Research demonstration projects for women’s treatment
Women’s special needs and the delineation of gender specific treatment strategies were identified over 20 years ago
Beschner, Reed, & Mondanaro (Eds) 1981Treatment services for drug dependent women
History of Specialized Services for WomenHistory of Specialized Services for Women
Federal grant programs, e.g. NIDA Perinatal 20 and CSAT pregnant and post-partum demonstration grants, provided support for development and enhancement of women’s treatment services in the late 80’s –’90’s
Specialized Treatment Services for Women Specialized Treatment Services for Women
Programs in US– Residential: 41% women-only
23% pregnant/postpartum women
(SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS) 2001)
Of women who need treatment only 20% receive treatment
(SAMHSA, OAS 2002)
Services: Models for Women’s TreatmentServices: Models for Women’s Treatment
Finnegan, Hagan, Kaltenbach (1991)Scientific foundation of clinical practice: Opiate use in
pregnant womenJansson, Svikis, et al (1996) Pregnancy and addiction: A comprehensive care
modelKaltenbach & Comfort (1996) Comprehensive treatment for pregnant substance
abusing womenFinkelstein, Kennedy, Thomas, Kearns (1997) Gender
specific substance abuse treatment
Woman Centered Treatment ModelWoman Centered Treatment Model
Comprehensive treatment approach that addresses – Addiction– Medical/Psychiatric – Psychosocial– Parenting– Educational/Vocational
issues of both women and their children
Specialized ProgramsSpecialized Programs
Women-only programs more likely to provide:Pregnancy, pediatric and children’s servicesClient advocacy/case managementClasses on social skills, practical skills, parenting, anger managementAssistance with housing and transportationPeer support groups and social outings
(Grella et al., 1999)
Effectiveness of Specialized Treatment ServicesEffectiveness of Specialized Treatment Services
Residential– Women in women-only programs had
More time in treatment
More likely to complete treatment
(Grella, 1999)
Effectiveness of Specialized Treatment ServicesEffectiveness of Specialized Treatment Services
Women in gender-specialized programs– Use more services throughout
treatment than women in traditional coed program
– Have higher rates of abstinence– More likely to see themselves as doing
well in treatment
(Nelson-Zupko, 1997)
Effectiveness of Woman Centered TreatmentEffectiveness of Woman Centered Treatment
Treatment for Pregnant Women:– Increased Gestational Age, Birth-weight,
Apgar Scores– Less likely to require NICU services– Those admitted to NICU had shorter stays– Average net savings for women in
treatment of $4,644 per moth/infant pair
(Svikis, et.al., 1997)
Assessing Comprehensive Treatment Needs of WomenAssessing Comprehensive Treatment Needs of Women
Instruments– Most assessment tools are based primarily on
males– Addiction Severity Index
Most widely used standard data collection instrument
Initially developed and tested solely on malesAcceptable levels of reliability and validity with a number of populations
Limited in assessing critical areas for women
Assessing Comprehensive Needs of WomenAssessing Comprehensive Needs of Women
ASI limited in assessing
Medical issues related to pregnancy Care-giving responsibilities Child and partner relationships Victimization
Assessing Comprehensive Needs of WomenAssessing Comprehensive Needs of Women
Psychosocial History (PSH)– Instrument that retains the fundamental structure
of the ASI but expanded to include Family history and relationships
Relationships with partner
Responsibilities for children
Pregnancy history
History of violence and victimization
Family legal issues
Housing arrangements
Complexity of NeedsComplexity of Needs
Personal and Family Characteristics
Residential Outpatient
Age 27.9 29.6
Education 11.8 10.8
Employment 77% 94%
Job training 48% 38%
(Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999)
Personal and Family CharacteristicsPersonal and Family Characteristics
Residential Outpatient
Currently Receiving
Public Assistance 84% 81%
Relationship status
Married 6% 17%
Not Married 84% 53%
Long-term
relationship 10% 30%
Personal and Family CharacteristicsPersonal and Family Characteristics
Residential Outpatient
Housing History
Homeless in past 3 yr. 68% 21%
Current Living arrangements
Family/Friends 51% 43%
Father of Baby 10% 29%
Shelter 26% 7%
No Stable Housing 6% 7%
Other 6% 14%
Personal and Family CharacteristicsPersonal and Family Characteristics
Substance Use by Partner
No use 31% 33%Drug and/or alcohol use 42% 42%Recovery 27% 25%D/A TreatmentEver 41% 40%Currently 15% 25%
Personal and Family CharacteristicsPersonal and Family Characteristics
Substance Use by Family
RT OP
No Yes No Yes
Biological mother 53% 37% 37% 53%
Biological father 27% 67% 28% 72%
Female caregiver 89% 11% 67% 33%
Male caregiver 100% 20% 80%
Maternal grandmother 58% 42% 72% 21%
Maternal grandfather 43% 50% 45% 55%
Personal CharacteristicsPersonal Characteristics
VictimizationResidential Outpatient
One/more types of victimization 73% 89%
Domestic violence 45% 65%
Rape 43% 54%
Childhood abuse/neglect 32% 39%
Personal CharacteristicsPersonal Characteristics
Legal Status Residential Outpatient
Family legal problems 45% 31%
Requested order of protection 22% 23%
Ever arrested 32% 23%
Ever incarcerated 23% 13%
Treatment OutcomesTreatment Outcomes
What are the factors that result in successful outcomes?– Literature reflects a variety of conceptual
frameworks that are ‘gender neutral”Patient-treatment matching
Motivation to change
Treatment process
Retention in treatment
Treatment OutcomesTreatment Outcomes
We know relatively little of the relationship between women’s characteristics/needs and treatment outcome.
Treatment OutcomesTreatment Outcomes
Retrospective study of 133 pregnant women enrolled in comprehensive gender specific outpatient treatment to identify factors that predict retention, abstinence, and service utilization
(Comfort & Kaltenbach, Substance Abuse, 2000)
Treatment OutcomesTreatment Outcomes
Measures– PSH
Factor analyses procedures reduced set of predictors to 27 variables organized into five factors
– Personal Stability– Opiate Dependence– Psychiatric and Medical problems– Multiple family problems– High-risk lifestyle
Treatment OutcomesTreatment Outcomes
Summary of FindingsRetention predicted by
Personal Stability
Opiate Dependence
Fewer Psychiatric and Medical Problems
Multiple Family Problems(multiple R2=.153, p<.0001)
Treatment OutcomesTreatment Outcomes
Summary of Findings
Abstinence predicted byLower scores on High-Risk Lifestyle (trend)
(multiple R2=.035, p=.059)
Treatment OutcomesTreatment Outcomes
Summary of Findings
Utilization of Required ServicesLower scores on Multiple Family Problems(multiple R2=.069, p=.021)
Utilization of Specialized Services Psychiatric and Medical Services (trend)(multiple R2=.045, p=.061)
Treatment OutcomesTreatment Outcomes
Prospective Longitudinal Study
– Women (95) enrolled for a minimum of 3 months with 12 month follow-up data
Outpatient (60)
Residential (35)
(Comfort & Kaltenbach, Addictive Behaviors, 2003)
Treatment OutcomesTreatment Outcomes
Treatment Outcome Variables– Treatment duration– Intensity of service utilization– Engagement in treatment– Satisfaction with treatment services– Substance use during treatment
Treatment OutcomesTreatment Outcomes
Summary: Outpatient
– The most noteworthy predictors for women in outpatient treatment were differing combinations of
Social supportLife stressorsLevels of past substance abuseChronic medical conditions
Treatment OutcomesTreatment Outcomes
Summary: Residential
– The most significant predictors for women in residential treatment reflected lower levels of personal risk factors
Partner abuseProstitutionHomelessnessDepression
Treatment OutcomesTreatment Outcomes
– More responsibilitiesCare-giving responsibilities
Less financial assistance from family
Treatment OutcomesTreatment Outcomes
Conclusion– No simple predictors of women’s
substance abuse treatment outcomes– Assessment areas of particular value
Social support Chronic medical problemsDaily stressors Childbirth historyLife satisfaction Childcare responsibilitiesPartner abuse Engagement in treatmentPsychiatric history
Predictors of Program Completion for Women in Residential TreatmentPredictors of Program Completion for Women in Residential Treatment
Five domains of patient characteristics to predict completion of treatment:Socio-demographics
Substance use
Legal involvement
Psychological functioning
Social relations (Knight et.al. Am J Drug Alcohol Abuse, 2001)
Predictors of Program Completion for Women in Residential Treatment Predictors of Program Completion for Women in Residential Treatment
Predictors of treatment completion– Education– Recent arrests– Peer deviance
(Knight et. al. 2001)
Predictors of Program Completion for Women in Residential TreatmentPredictors of Program Completion for Women in Residential Treatment
Noteworthy trendsWomen who were not married
Women who had two or more children
Women who had an open child welfare case
Women who had psychological problems
Appeared to be at greater risk for non-completion
(Knight et. al. 2001)
Treatment for WomenTreatment for Women
In summary, limited research on gender specific treatment
Biopsychosocial characteristics of women
Treatment utilization and retention
Psychiatric co-morbidity
Treatment for WomenTreatment for Women
Need for continued research– Development of assessments that reflect
the complex issues of pregnant and parenting drug dependent women
– Systematic investigations of barriers to treatment
– Pharmacological treatment and pregnancy– Treatment outcomes for mother and child